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A  TEXT-BOOK 


OK  THE 


THEORY  AND  PRACTICE 


MEDICINE. 


BY 


AMERICAN   TEACHERS. 


EDITED   BY 

WILLIAM    PEPPER,  M.  D.,  LL.D., 

Provost  and  Professor  of  the  Theory  and  Practice  of  Medicine  and  of  Clinical  Medicine 

in  the  University  of  Pennsylvania. 


in  two  volumes- illustrated. 
Vol.  L 


I'  11  I  \.\  1)  K  L  1'  IN  A: 

w.  H.  s  A  u  N  I )  i:  us, 

913  Walntit  Sthket. 
1893. 


Copyright,  1893,  by 
W.     B.    SAUNDERS. 


ELEOTnOTYPED  BY  PRINTED  BY 

WESTCOTT  &  THOMSON,  PllILADA.  EDWARD   STERN   &   CO.,  PHILADA. 


LIST  OF  AUTHORS. 


J.  S.  BILLINGS,  M.  D., 

Professor  of   Hygiene,  University  of   Pennsylvania;    Cnrator  Aimy  Medical   Museum    and 
Library,  Washington,  D.  C. 

FRANCIS  DELAFIELD,  M.  D., 

Profesor  of  Pathology  and  Practice  of  Medicine,  College  of  Physicians  and  Surgeons,  New 
York  City. 

R.  H.  FITZ,  M.  D., 

Shattuck  Professor  of  Pathological  Anatomy,  Harvard  Medical  School. 

JAMES  W.  HOLLAND,  M.  D., 

Professor  of  Medical  Chemistry  and  Toxicology,  Jetferson  Medical  College,  Philadelphia. 

E.  G.  JANEWAY,  M.  D., 

Professor  of  Principles  and  Practice  of  Medicine,  Bellevue  Hospital  Medical  College,  New 
York  City. 

HENRY  M.  LYMAN,  M.  D., 

Professor  of  Principles  and  Practice  of  Medicine,  Rush  Medical  College,  Chicago,  111. 

WILLIAM  OSLER,  M.  D., 

Professor  of   Practice  of   Medicine,  Johns  Hopkins  University,   Physician  in  Chief  to  the 
Johns  Hopkins  Hospital,  Baltimore,  Md. 

WILLIAM  PEPPER,  M.  D., 

Provost  and  Professor  of  the  Theory  ami   Practice  of   Medicine  and  of  Clinical   Medicine, 
University  of   Pennsylvania. 

W.  GILMAN  THOMPSON,  M.  D., 

Professor  of  Piiysiology  in  the  Mi-dical   Department  of  tin    University  of  the  City  of  New 
York. 

W.  il.   \\'EL(;iI,  M.  D., 

Professor  of  Pathology,  .Irilms  il(i|ikiiis   Uiiivt^rsity,  Haltinjort^,  .Mil. 


iv  LIST   OF   AUTHORS. 

JAMES  T.  WHITTAKER,  M.  D., 

Professor  of  tlie  Theory  and    Practice  of   Medicine,  Medical  College  of  Ohio,  Cincinnati ; 
Lecturer  ou  Clinical  Medicine,  Good  Samaritan  Hospital,  Cincinnati,  Ohio. 

JAMES  C.  WILSON,  M.  1)., 

Professor  of  Practice  of  Medicine  and  Clinical  Medicine,  Jefferson  Medical  College,   Pliil- 
adc^lphia. 

HORATIO  C.  WOOD,  M.  D., 

Professor  of  Therapeutics  and  Clinical  Professor  of  Nervous  Diseases,  University  of  Penn- 
sylvania. 


PREFACE 


In  the  preparation  of  this  work  some  of  the  teachers  of  Pi'aotical  IVFedi- 
eine  in  leading  schools  of  America  have  associated  themselves,  in  order  that 
each  snbject  should  be  discussed  by  an  expert  of  special  authority.  It  may, 
then,  be  said  to  represent  truly  the  best  teaching  of  the  science  and  art 
of  Medicine  at  the  present  time  in  this  country.  As  such  it  is  oifered  to 
the  medical  profession  and  to  the  large  body  of  our  medical  students,  with 
the  earnest  hope  that  it  will  be  found  to  meet  their  needs  and  to  })rove  a  safe 
guide.  Especial  care  has  been  taken  to  provide  a  strong  article  on  Hygiene, 
including  the  full  discussion  of  disinfection,  isolation,  and  other  principles  of 
preventive  medicine.  Bacteriology  is  treated  at  length  by  an  eminent  author- 
ity, while  in  connection  with  each  of  the  infectious  diseases  full  consideration 
is  given  to  the  nature  and  cause  of  the  morbid  process.  The  important  subject 
of  Intestinal  Parasites  is  presented  with  unusual  fulness.  Here,  as  well  as  in 
connection  with  bacteriology,  no  pains  have  been  spared  to  provide  the  best 
illustrations  ;  so,  too,  wherever  the  text  lias  seemed  to  require  it,  charts  and 
diagrams  have  been   freely   used. 

The  object  of  the  work  is  essentially  a  practical  one.  The  subjects  are 
treated  in  an  autiioritative  manner.  It  has  been  impossible  to  give  space  for 
bibliographical  lists  or  for  many  references.  Any  apparent  absence  of  recog- 
nition of  the  views  of  other  writers  must  be  attributed  to  this  cause. 

The  sections  on  Symi)tomatol()gy,  Diagnosis,  and  Treatment  are  especially 
full,  and  many  formuhe  are  admitted. 

Important  assistance  has  been  rendered  in  the  preparation  of  this  work   by 

Dr.  F.  A.  Packard,  who  has  been  associated  with  the  Editor  in  the  revision 

of  MSS.  and  the  correction  ol'  the  proof-sheets. 

WILLIAM    I'KPPER. 
1811  Spruce  St.,  Philauici.phia,  ) 
January  30,  1893.  i" 


CONTENTS. 


PAGE 

HYGIENE 1 

By  John  S.  Billings. 

EPHEMERAL  FEVER  AND  SIMPLE  CONTINUED  FEVER 40 

By  William  Pepper. 

TYPHOID  FEVER 52 

By  William  Pepper. 

TYPHUS  FEVER 134 

By  William  Pepper. 

RELAPSING  FEVER 150 

By  William   Pei'PER. 

CEREBROSPINAL  FEVER IGli 

By   William  Pepper. 

INFLIENZ.V 184 

P>Y  WiLMA.M    Pepper. 

DEN<;UK     197 

By  Willia.m   Pepper. 

MILIARY  FEVER 201 

By  William  Pepper. 

MILK  SICKNESS 2'^4 

I>Y  William   Pkppkk. 

M(JUNTAIN  FEVP:R 207 

By  William    Prpprf;. 

SCARLATINA 20.S 

By  Jamks  T.  Wiiittaker. 

MEASLES • 2:50 

15  Y  Jamks  T.   Willi  taker. 

RUBELLA 254 

By  .Jame-s  T.  Wiiittaker. 

SMALL-POX 201 

P>Y  .Jamics  T.  Willi  taker. 

vii 


viii  CONTENTS. 

PAGE 

VACCINATION 283 

By  James  T.  Whittakkr. 

VARICELLA  . 297 

By  James  T.  Whittaker. 

MUMPS 304 

By  James  T    Whittaker. 

WHOOPING  COUGH 311 

By  James  T.  Whittaker. 

SEPTICEMIA  AND  PYAEMIA 324 

By  William  Pepper. 

ACUTE   MILIARY  TUBERCULOSIS 329 

By  W.  Oilman  Thompson. 

SCROFULA 336 

By  W.  Oilman  Thompson. 

SYPHILIS 345 

By  W.  Oilman  Thompson. 

LEPROSY 369 

By  W^illiam  Pepper. 

DIPHTHERIA      373 

By  W.  Oilman  Thompson. 

ERYSIPELAS 397 

By  W.  Oilman  Thompson. 

MALARIAL  FEVERS 405 

By'  W.  Gilman  Thompson. 

CHOLERA       434 

By  W.  Oilman  Thompson. 

YELLOW  FEVER 451 

By  W.  Oilman  Thompson. 

TETANUS 462 

By  James  T.  Whittaker. 

ACTINOMYCOSIS 473 

By  James  T.  Whittaker. 

ANTHRAX 478 

By  James  T.  Whittakkr. 

HYDROPHOBIA       485 

By  James  T.  Whittaker. 

TRICHINOSIS 499 

By  James  T.  Whittaker. 

GLANDERS 512 

By  James  T.  Whittaker. 


coxTJcyrs.  i\ 

PACK 

FOOT-AND-MOUTH    DISEASE ,jl!> 

By  James  T.  Whittaker. 

GENERAL  SYMPTOMATOLOGY  OF  DISEASES  OK  THE  NERVOUS  SYSTEM  .  523 

By  Horatio  C.   Wood. 

MENTAL   DISEASES ryld 

By  Horatio  C.  Wood. 

FUNCTIONAL   NERVOUS  DISEASES 587 

By  Horatio  ('.  Wood. 

ORGANIC   DISEASES   OF   THE  BRAIN 669 

By  Wii.i.iam  O.-^lek. 

SY  Bin  LIS  OF   THE  NERVOUS   SYSTEM 726 

By  Horatio  C.  Wood. 

0R(;ANIC   diseases  of   the  spinal  cord   and    ITS  MEMBRANES  .    ■    .  737 
By  Horatio  C.  Wood. 

DISEASES   OF   THE   NERVES , .-        .    .    .    .  80o 

By  William  Osler. 

DISEASES  OF   THE    MUSCLES 850 

By  Willlxm  Osler. 

VASO-MOTOR   AND  TROPHIC   DISORDERS .    .    ■  855» 

I5y   William  Oslkh. 


LIST  OF  ILLUSTRATIONS. 


FIGURES. 


FIGVRK  PAGK 

1.  Diagram  showing  Relative  Freqiiency  of  Sniall-pox   Belore  and  After  Compulsory 

Vaccination 14 

2.  Diagram  showing  Deaths  from  Scarlatina  in  Providence 15 

3.  Typical  Temperature-chart  of  Typhoid  Fever 73 

4.  Temperature-chart  of  Case  of  Typhoid  Fever,  showing  prolonged  hyperpyrexia    .    .  77 
o.  Teniperature-cliart  of  Case  of  Typhoid   Fever,  showing  effect  of  intestinal   hrpmor- 

rhage 86 

6.  Temperature-chart  of  Case  of  Typhoid  Fever,  showing  pseudo-relapse 94 

7.  Temperature-chart  of  Case  of  Typlioid  Fever,  showing  effects  of  complications  ...  96 

8.  Temperature-chart  of  C;isc  of  Abortive  Typhoid  Fever 86 

9.  Temperature-chart  of  Case  of  Typhoid  Fever,  showing  results  of  Brand  method  of 

treatment 121 

10.  Temperature-chart  of  Case  of  Typhus  Fever 139 

11.  Spirilla  of  Kelajjsing  Fever 151 

12.  Chart  showing  Deatii-rate  of  Pneumonia  din-ing  E|)idemic  of  Infliicn/.a 191 

13.  Temperature-chart  of  Mild  Case  of  Scarlatina 215 

14.  Temperature-chart  of  Case  of  Measles,  showing  defervescence  by  crisis 238 

15.  Temperature-chart  of  Ordinary  Ca.se  of  Measles 238 

16.  Temperature-chart  of  Four  Cases  of  Measles  up  t(»  Appearance  of  Eruption  ....  240 

17.  Temperature-chart  of  Ca.se  of  Measles  following  Scarlatina 242 

IS.     Capillary  of  Skin  in  Small-pox 264 

19.  Section  of  Variolous  Lesion  of  Skin      271 

20.  Temj)erature-chart  of  Case  of  Small-pox      272 

21.  Diagram  sliowing  Mortality  from  Small-pox  in  Prussia  and  .Vustria 290 

22.  Temperature-chart  of  Case  of  Acute  Miliary  Tuberculosis 333 

23.  Central  Incisor  Teeth  of  Hereditary  Syphilis 3(54 

24.  Forms  of  Plasmodium  Malaria?              407 

25.  Temperature-<-hart  of  Ca.se  of  (Quotidian   IiitcriniUciit    i"«ver 415 

26.  Temperatnre-chait  of  Cjise  f)f  Tertian  Intermittent  Fever 116 

27.  Temperature-chart  of  Case  of  Hemittent  i''ever 424 

28.  Comma-bacillus  of  Cholera 437 

29.  Actinomyces 474 

30.  Actinomyces  Stained  by  Gram's  Method 475 

31.  Anthrax-bacilli 479 

zi 


xii  LmT    OF  ILLUSTRATIONS. 

FIGURE  PAGE 

32.  .Section  of  Hypoglossal  Nucleus  of  Case  of  Hydrophobia 492 

33.  Section  showing  Miliary  Aliscess  in  Fibres  of  Origin  of  Hypoglossal  Nucleus  of  Case 

of  Hydrophobia 492 

34.  Meischner's  Sac 501 

35.  End  of  Meischner's  Sac,  with  kidney -shaped  bodies  free  and  enclosed 501 

30.     Uninipregnated  Female  Trichina 502 

37.  Male  anil  Female  Trichinae,  female  discharging  young      502 

38.  Trichiuic  in  Muscle  near  Tendinous  Insertion 503 

39.  Living  Embryos  of  Trichina 504 

40.  Encapsulated  Trichina      504 

41.  Calcified  Trichina      505 

■12.     Calcified  Trichina'  (natural  size) 505 

43.  Case  of  Glanders  with  Tubercles  upon  Ahc  Nasi 514 

44.  Temperature-chart  of  a  Case  of  Puerperal  Insanity 573 

45.  Latei-al  Surface  of  Brain  of  Monkey,  showing  motor  area 096 

46.  Median  Surface  of  Brain  of  Monkey,  sliowing  motor  area 697 

47.  Diagram  showing  Arrangement  of  Motor  Fibres  in  Internal  Capsule 698 

48.  Lichtheim's  Schema 701 

49.  Diagraiimiatic  Section  of  Spinal  ('(inl 737 

50.  Diagram  of  (Jroups  of  Cells  in  Anterior  Cornu 738 

51.  Diagram  of  Levels  of  Nerve-roots  and  Vertebrne 739 

52.  Tabetic  Feet 783 

53.  Impression  of  Tabetic  Feet 783 

54.  Tabetic  Hand 783 

55.  Multijile  .Mcoholic  Neuritis 808 

56.  Diagram  of  Visual  Paths 817 

57.  Diagram  of  Mot(U-  Tract      829 

58.  Pseudo-jiypertrophic  Muscular  Paralysis      853 

PLATES. 

PLATE  Opposite  page 

I.     Ihrmatozoon  of  Malaria 407 

II.     .Vreas  involved  in  \'arious  Forms  of  Aphasia 705 

III.     Acromegaly 863 


HYGIENE. 

By  JOHN  S.  BILLINGS. 


Instruction  in  hygiene  for  the  medical  student  has,  until  recently,  been 
considered  as  theoretically  desirable,  but  practically  unessential.  To  the  stu- 
dent entering  on  his  course  of  medical  study  the  question  may  arise,  "Why 
should  a  physician  be  compelled  to  learn  how  to  prevent  disease?"  From  the 
business  point  of  view  he  is  to  support  himself  and  his  family  by  treating  the 
sick  :  why,  then,  should  he  try  to  prevent  the  occurrence  of  sickness  and 
thus  lessen  the  chances  for  his  employment?  The  answers  to  this  are  as 
follows : 

First :  From  the  business  point  of  view  the  man  who  has  studied  modern 
hygiene  is  more  apt  to  obtain  and  retain  employment  as  a  practitioner  than 
one  who  has  not.  The  laws  of  several  States  already  require  a  knowledge  of 
hygiene  by  those  to  whom  license  to  practise  medicine  is  given  ;  the  medical 
examining  boards  of  the  army,  navy,  and  marine-hospital  service  lay  special 
stress  on  the  knowledge  of  hygiene  possessed  by  the  candidates  who  come 
before  them ;  and  the  same  may  be  said  for  the  civil-service  examinations 
for  filling  various  offices  in  which  medical  knowledge  is  essential.  Tliere  is,  in 
fact,  a  rapidly-growing  demand  on  the  part  of  the  public  tiiat  physicians  shall 
receive  special  instruction  as  to  the  causes  of  disease  and  the  means  of  prevent- 
ing or  destroying  those  causes,  as  well  as  in  the  treatment  of  the  diseases  pro- 
duced by  them  ;  and  this  demand  exists  not  only  with  examiin'ng  boards,  but 
with  tlie  men  and  women  who  employ  physicians  in  private  life.  The  people 
who  pay  medical  bills  want  to  know  the  cause  of  their  sickness ;  whether  their 
houses  are  in  good  sanitary  condition,  and  if  not,  why  not,  and  what  should 
be  done  about  it ;  whether  the  water  is  safe  to  drink  ;  and  many  other  things 
for  which  they  consult  their  physicians.  Moreover,  hygiene  is  not  only  the  art 
of  preserving  health,  but  of  improving  it,  and  is  a  most  important  part  of  the 
therapeutics  of  many  forms  of  disease. 

8(;cond  :  It  is  the  duty  of  the  physician   (o  prevent  disease  whenever  and 
wherever  he  can,  without  reference  to  any  considerations  as  to  whether  iiis 
Vol.  I.— 1  1 


2  HYGIENE. 

doing  so  will  be  of  any  pecuniary  benefit  to  himself  or  not,  and  to  be  fully 
informed  as  to  the  best  methods  of  doing  this.  It  is  true  that  the  health 
interests  of  the  people  among  whom  he  lives  and  works  ai'e  his  own  interests, 
because  if  they  suffer  he  and  his  family  must  also  suffer;  but,  without  refer- 
ence to  this,  or  to  his  obligations  as  a  husband  or  father,  it  is  his  special  duty 
as  an  educated  medical  man  to  consider  and  advise  upon  sanitary  problems  for 
the  benefit  of  those  who  have  not  this  expert  knowledge.  It  is  the  most  direct 
and  certain  way  in  which  he  can  serve  God  and  his  fellow-man. 

Questions  of  public  hygiene  are  becoming  more  and  more  prominent  in  the 
social  and  political  world  :  all  efforts  to  make  the  mass  of  the  people  more 
contented  and  comfortable  are  connected  with  health  questions,  and  there  is 
great  need  of  scientifically  educated  men  who  will  not  be  induced  through 
ignorant  enthusiasm  to  endorse  the  numerous  quack  reform  schemes  which  are 
being  continually  proposed  and  thrust  upon  the  public. 

There  has  been,  and  still  is,  a  vast  amount  of  charlatanry,  humbug,  and 
advertising  in  so-called  sanitary  literature,  especially  in  that  part  of  it  devoted 
to  attempts  to  scare  people  into  buying  some  patent  contrivance  or  article  of 
food  or  drink  ;  and  it  is  a  part  of  the  business  of  the  physician  to  know  when 
there  is  real  danger  and  what  is  best  to  be  done  under  the  circumstances. 
Half-knowledge  in  these  matters  produces  much  unnecessary  anxiety  and 
fear. 

Health  is  a  means,  not  an  end.  In  every-day  life  many  men  deliberately 
choose  an  occupation  and  a  place  of  residence  which  they  know  involve  a  cer- 
tain extra  risk  to  health  and  life ;  in  fact,  the  physician  does  this  himself.  In 
insuring  health  and  life,  as  well  as  property,  the  question  occasionally  comes  up, 
"  What  is  the  greatest  amount  of  premium  that  it  is  worth  while  to  pay  for 
such  insurance?"  There Js  both  an  upper  and  a  lower  limit.  Some  cannot 
afford  to  insure  at  all. 

Compulsory  legislation  for  securing  the  health  of  a  community  must  be 
framed  with  reference  to  economic  consequences  as  well  as  to  health. 

The  public  hygiene  of  to-day  dates  from  about  fifty  years  ago,  the  time 
when  a  really  useful  system  of  vital  statistics  was  established  for  England  by 
Dr.  William  Farr.  Prior  to  that  time  the  causes  and  mode  of  preventing 
scurvy  had  been  discovered,  vaccination  had  been  introduced,  and  much  was 
known  about  personal  hygiene ;  but  very  little  was  known  about  the  health 
of  communities  or  particular  cities,  or  whether  it  was  becoming  better  or 
worse. 

The  cholera  epidemic  of  1849  in  England  gave  a  powerful  stimulus  to 
investigation,  which  was  made  by  the  Health  of  Towns  Commissions  ;  but  the 
Crimean  War,  with  its  positive  demonstration  of  the  effects  of  sanitation  elab- 
orated and  insisted  on  by  Dr.  Parkes,  was  what  finally  convinced  the  govern- 
mental authorities  of  its  inijiortance  and  necessity.  Next  came  the  stage  of 
<areful  study  of  the  causes  of  various  diseases  by  experiment  and  observation 
under  the  direction  of  Mr.  John  Simon  as  medical  officer  of  the  Privy  Coun- 
cil, and  of  his  successor,  Dr.  (now  Sir)  George  Buchanan,  until  recently  the 


HYGIEXE.  3 

medical  officer  of  the  Local  Government  Board,  and,  finally,  the  ^vork  of  Pas- 
teur and  Koch  and  their  followers  in  bacteriologv  and  its  relations  to  contaffious, 
infectious,  and  epidemic  disease,  which  are  now  leadhig  to  practical  results  of 
the  greatest  importance. 

Hvo;iene,  as  applied  to  man,  includes  the  study  of  his  relations  to  those  sur- 
roundings which  influence  his  health  and  longevity,  and  the  practical  application 
of  the  results  of  this  study. 

The  end  of  each  human  life  is  fixed,  in  one  sense  of  the  word  :  there  is  a 
maximum  which  it  cannot  pass.  But  in  another  sense  it  is  movable,  and  may 
be  hastened  or  postponed  by  surrounding  circumstances.  Mere  postponement 
of  death  is,  however,  not  always  desirable,  for  life  itself  may  be  a  burden,  and 
to  be  desirable  it  should  be  healthy  and  productive.  A  really  sound,  healthy 
man  is,  to  a  considerable  extent,  independent  of  surrounding  circumstances:  he 
does  not  have  to  regulate  his  diet  minutely,  to  adjust  his  clothing  to  every 
change  of  weather,  or  to  be  continually  guarding  against  possible  causes  of  dis- 
turbance of  function  in  order  that  he  mav  be  able  to  live  and  do  his  work. 
There  was  some  truth  in  the  old  proverb  that  to  live  medically  is  to  live 
miserably. 

From  the  hygienic  standpoint  the  causes  of  disease  may  be  classified  as 
follows:  (a)  causes  acting  from  within,  or  predisposing  causes,  including  (1) 
heredity,  (2)  individual  peculiarities,  connate  or  acquired  after  birth,  but  not 
inherited ;  (B)  mental  and  emotional  causes ;  (C)  causes  acting  from  without, 
immediate  or  exciting  causes,  including  (1)  physical,  mechanical,  and  chemical 
causes,  (2)  micro-organisms. 

Those  causes  which  are  more  or  less  under  our  control,  and  which  therefore 
may  be  modified,  prevented,  or  avoided,  are  of  special  practical  interest ;  but 
the  so-called  unavoidable  causes  must  also  be  studied,  partly  because  the  disease 
or  source  of  injury  or  nuisance  against  which  we  can  to-day  devise  no  protec- 
tion may,  in  the  rapid  advance  of  science,  be  to-morrow  within  our  control  ; 
and  partly  because  we  must  know  what  and  how  nuich  disease  is  due  to  un- 
j)reventable  causes  in  order  to  understand  the  real  scope  and  results  of  those 
influences  which  we  can  hope  to  modify. 

For  example,  the  effects  of  weather,  including  especially  excessive  cold, 
dampness,  or  heat,  upon  the  health  and  life  of  the  poorer  classes  in  large  cities 
are  often  very  marked  ;  hence  these  nnist  be  carefully  considered  in  comparing 
the  death-rates  of  two  diflerent  years  in  order  to  <letermiiie  wliclhci-  a  watcr- 
suj)ply  is  b(;coming  worse  or  better,  or  whcthiT  the  system  of  sewage-disposal 
is  producing  satisfactory  results. 

Our  knowledge  of  ihe  causes  of  disease  is  derivcil  from  (ibscrxation  :iiid 
experiment,  the  latter  being  in  the  main  limited  to  those  diseases  which  can  be 
indu(;ed  or  ])rodueed  in  atiimals.  Observation  may  be  ap|)lied  to  individual 
cases  (»r  to  communities.  I>y  tlie  first  we  eompan;  indivi<hial  with  indiviihial 
and  mimitelv;  bv  the  second  we  eom|)are  (he  vital  phenomena  of  communities, 
l)ii)  onlv  on  broad  lines  and  witli  regard  to  circumstances  (-asily  noted. 


4  HYGIENE. 

To  ascertain  whether  a  block  of  houses  or  a  town  is  unhealtliy,  whether  it 
is  getting  worse  or  better,  and  what  is  the  matter,  we  must  obtain  certain  infor- 
mation with  regard  to  the  amount,  character,  and  fatality  of  the  diseases  pre- 
vailing in  the  place ;  and  the  most  important  means  of  doing  this  is  by  exam- 
ining the  mortality  statistics.  Mortality  does  not  mean  the  number  of  deaths, 
but  the  death-rate,  or  liability  to  death,  as  shown  by  comparing  the  number  of 
deaths  in  a  given  time  with  the  quantity  of  life  in  which  they  have  occurred. 
It  refers  to  a  definite  unit  of  time — viz.  one  year's  life  of  one  person — and  the 
quantity  of  life  is  the  sum  of  the  time  lived  by  each  of  the  population  expressed 
in  years ;  thus,  five  men  living  one  year,  or  ten  men  living  six  months  each,  or 
sixty  persons  living  one  month  each,  give  five  years  of  life.  The  number  of 
years  of  life  is  usually  stated  as  being  the  mean  population  for  the  year,  and 
the  annual  death-rate  is  given  for  each  thousand  of  mean  population.  It  is 
computed  by  adding  three  ciphers  to  the  number  of  deaths  occurring  during 
the  year  and  dividing  by  the  number  of  mean  population  for  that  year.  Thus, 
if  there  were  350  deaths  in  a  yeai*  in  a  city  of  20,000  mean  population,  the 
death-rate  would  be  350,000  divided  by  20,000,  equal  to  17.5  per  1000.  If 
the  time  for  which  the  mortality  is  calculated  is  less  than  a  year,  the  result  must 
be  reduced  to  an  annual  ratio ;  thus,  if  the  number  of  deaths  in  one  week  be 
given,  this  number  must  be  multiplied  by  52.177,  the  number  of  weeks  in  a 
year,  and  the  product  by  1000,  and  divided  by  the  mean  population,  to  give 
the  annual  death-rate.  A  more  convenient,  and  sufficiently  accurate,  method 
is  to  divide  the  mean  population  by  52,  and  use  the  quotient  throughout  the 
year  as  the  constant  divisor  for  the  weekly  number  of  deaths  multiplied  by  1000. 
The  mean  population  is  ascertained  either  by  an  actual  count  or  census  taken 
in  the  middle  of  the  year,  or  (and  usually)  by  computation  from  the  data 
given  by  two  successive  counts,  from  which  is  ascertained  the  annual  rate  of 
increase. 

It  is  usually  assumed  that  a  population  increases  in  geometrical  progression, 
and  the  calculation  is  made  by  the  use  of  logarithms  according  to  the  following 
formulae,  in  which  r=  annual  ratio  of  increase,  p  =  population  at  last  census, 
p'=  population  at  present  census,  n  =  number  of  years  between  these  two  cen- 
suses, x=  mean  population  sought,  and  w'=  number  of  years  between  last  cen- 
sus and  the  time  for  which  the  population  is  sought: 

log  r  =     ^  J^     — ^J-  J  and  log  x  =  log  p'  +  log  r  X  n', 
n 

The  mean  population  for  a  period,  as  found  by  this  geometrical-progression 
formula,  is  greater  than  the  population  actually  living  in  the  middle  of  the 
period,  and  less  than  the  arithmetical  mean  of  the  popidation  living  at  the 
beginning  and  end  of  the  })eriod  ;  but  if  the  period  be  only  a  year  or  two,  the 
differences  are  small  and  either  figure  may  be  used. 

The  assumption  that  the  population  is  increasing  regularly  in  geometrical 
progression  is  rarely  correct,  and  when  the  census  is  taken  only  once  in  ten 


HYGIENE.  5 

years  it  may  lead  to  very  erroneous  results.  Tlio  best  method  of  correctintr  the 
result  thus  obtained  is  by  comparing  it  witii  the  result  obtained  by  multiplying 
the  number  of  inhabited  houses,  as  shown  by  tax  records  or  personal  count, 
with  the  average  number  of  inhabitants  per  house  for  tiiat  particular  city,  as 
shown  by  the  previous  census.  Estimates  based  on  the  number  of  voters  or 
of  school-children  or  on  city  directories  are  almost  invariably  in  excess  of  the 
true  figures. 

The  number  of  deaths  is  ascertained  from  the  public  record  in  which  each 
death  is  registered  as  it  occurs.  No  system  of  registration  of  deaths  is  com- 
plete and  accurate  unless  a  permit  for  burial,  granted  by  some  public  official, 
is  required  in  each  case  of  death.  To  obtain  such  a  permit  a  certificate  must 
be  presented  stating  the  name,  age,  sex,  color,  residence,  etc.  of  the  dead  person 
and  the  cause  of  death.  The  certificate  as  to  the  cause  of  death  must  l)e  signed 
bv  some  one  who  is  competent  to  tell  whether  the  death  was  due  to  so-called 
natural  causes  or  to  crime.  Hence  it  must  be  signed  by  an  educated  physician, 
and  hence  the  matter  of  registration  of  deaths  is  one  of  great  importance  to 
medical  men,  for  it  is  the  foundation  of  state  legislation  to  determine  who  are 
"educated  physicians"  and  competent  to  sign  such  certificates. 

The  shorter  the  period  for  w^hich  a  death-rate  is  given,  and  the  smaller  the 
population  to  which  it  refers,  the  less  probable  it  is  that  it  is  to  be  relied  on  for 
purposes  of  comparison.  This  is  due  to  the  law  of  probable  error  as  connected 
witli  the  use  of  large  or  small  numbers. 

For  rough  calculations  it  may  be  assumed  that  the  possible  variation  in  the 
number  of  deaths  is  equal  to  the  square  root  of  that  number.  Thus,  if  16 
deaths  occur  in  a  year  in  a  village  of  1000  inhabitants,  the  possible  error  is  4, 
so  that  the  death-rate  might  vary  between  12  and  20  per  1000  without  giving 
any  certain  indications  of  corresponding  variation  in  the  sanitary  condition  of 
the  place ;  while  in  a  city  of  100,000  inhabitants,  with  IGOO  deaths  yearly,  the 
possible  variation  in  the  number  of  deaths  would  be  40,  so  that  the  death-rate 
could  only  vary  between  1 5.6  and  16.4  per  1000,  without  indicating  the  action  of 
some  special  cause. 

For  localities  for  which  the  jwpulation  cannot  be  determined,  or  for  which 
the  number  of  deaths  occurring  in  a  given  time  is  unknown,  death-rates  cannot 
be  calculated,  and  the  essential  foundation  for  a  useful  public  health  organiza- 
tion is  therefore  wanting. 

Fair  average  annual  death-rates  are  from  9  to  16  per  1000  in  rural  districts 
and  small  villages,  from  14  to  18  per  1000  in  towns  of  from  5000  to  20,000 
inhabitants,  from  17  to  20  per  1000  in  cities  of  from  25,000  to  100,000  inliab- 
itants,  and  from  18  to  21  per  1000  in  cities  of  over  100,000  inhabitants.  When 
death-rates  below  the  lowest  of  the  above  rates  are  given,  it  is  pr()l)abK'  that  the 
population  has  been  over-estimated  or  that  nil  the  deaths  have  not  been  counted, 
or  both  ;  when  they  are  higher  than  the  highest  ol"  llie  above  rates,  it  is  i)rob- 
able  that  some  special  cause  exists  for  the  high  mortality.  In  comparatively 
new  and  rapidly-growing  cities,  however,  the  large  proportion  of  adults  gives 
a  lower  general  death-rate  than  those  above  stated. 


HYGIENE. 


Gro.s.s  death-rates,  obtained  by  comparing  the  total  number  of  deaths  with 
the  total  mean  population,  although  useful,  are  not  nearly  so  useful  as  the 
death-rates  of  particular  classes  of  the  population,  and  especially  death-rates 
for  different  groups  of  ages  with  distinction  of  sex.  This  is  due  to  the  fact  that 
the  natural  tendency  to  death  varies  greatly  at  different  ages  ;  thus,  the  average 
annual  death-rate  of  children  under  five  years  of  age  is  from  50  to  100  per 
1000 ;  of  persons  between  five  and  twenty  years  of  age,  from  2  to  7 ;  between 
twenty  and  forty,  from  6  to  11  ;  between  forty  and  sixty,  from  12  to  25  ;  and 
over  sixty,  from  55  to  95  per  1000.  Hence  the  proportion  of  young  children 
and  of  old  persons  present  in  a  given  population  has  a  great  influence  on  its 
death-rate,  and,  unless  these  proportions  are  nearly  the  .same,  the  comparison 
of  the  gross  death-rates  of  two  different  populations  may  give  very  erroneous 
results.  This  al.so  applies  to  the  death-rates  of  different  occupations.  The 
death-rate  of  judges  and  major-generals  is  greater  than  that  of  students  or  lieu- 
tenants, becau.se  of  the  average  difference  in  ages. 

To  obtain  satisfactory  and  reliable  mortality  statistics  we  must  know  not 
only  the  population,  but  the  population  of  each  sex  at  different  groups  of  ages, 
and  the  number  of  deaths  in  a  given  time,  with  corresponding  distinctions  of 
sex  and  age. 

For  a  large  part  of  the  United  States  the  data  necessary  for  calculating 
death-rates  cannot  be  obtained  :  only  the  New  England  States,  New  York,  and 
New  Jersey  have  a  system  of  registration  of  deaths  which  gives  fairly  comj)lete 
results,  and  in  some  of  the.se  it  has  been  in  operation  but  a  short  time.  Even 
where  there  is  a  fairly  good  registration  of  deaths,  its  results  are  often  partially 
or  entirely  useless  for  calculating  death-rates  because  of  the  want  of  reliable 
information  as  to  the  number  of  population  at  different  ages. 

The  best  means  of  eliminating  the  influences  of  sex  and  age  on  death- 
rates  is  by  the  preparation  of  a  life  table,  from  which  can  be  determined  the 
expectation  of  life  at  each  age  in  each  sex,  such  as  that  shown  in  the  following 
tabk : 

Table  showing  Expectation  of  Life. 


Ages. 

0 

5 

10 

15 

25 

40 

60 

American  Life  Ins.  Co.     .    . 
Massachusetts,  l«83-87     .    . 

Jteton, 1883-87     

Providence,  1883-87     .    .    . 
New  York,  1879-81  .    .    .    . 
Baltimore,  1880,  colored  .    . 
Society  of  Friends,  Phila.    . 
Society  of  Friends,  p>n^land 
lienedictine  Monks,  Paris 

Males  .    .    . 
Males  .    .    . 
Persons    .    . 
Persons    .    . 
Males  .    .    . 
Males  .    .    . 
Persons    .    . 
Males  .    .    . 

39.7 
33.3 
40.8 
33  3 
21.0 
43.7 
45.3 

52.7 
47.2 
51.1 
48.0 
41.8 
51.8 
53.8 

50.6 
38.5 
44.9 

49.9 
49.3 
47.5 

48.3 
44.9 
40.0 

48.8 
50.5 

.    . 

45.6 
37.2 
43.1 

46.6 
45.1 
44.7 
44.2 
40.6 
36.8 
44.6 
46.4 

40.6 
33.4 
39.5 

39.5 
38.2 
37.1 
37.5 
33.2 
31.0 
37.5 
39.9 
34.6 
34.0 
27.0 
32.0 

28.5 
28.2 
28.5 
27.7 
23.9 
21.7 
28.5 
29.2 
24.0 
24.5 
19.8 
22.0 

14.5 
15.3 
16.7 
15.0 
13.0 
11.3 
15.6 
14.4 
11  7 

Knglish  Life  Insurance    .    . 

126 

Dublin,  1841 

Berlin      

Males  .    .    . 
Males  .    .    . 

23.8 
17.2 

11.0 
10.0 

From  this  table  it  will  be  .seen  that  at  the  age  of  twenty-five  the  mean 
expectation  of  life  of  that  class  of  American  males  who  insure  their  lives  is 


-1 


PREDLSPOSIXG   CAUSES  OF  DISEASE  7 

tliirty-iiine  and  a  half  years,  while  for  eolored  males  in  Jxiltiniore  it  is  only 
thirty-one  years. 

The  expeetation  of  life  is  the  mean  after-lifetime  ;  the  probable  duration  of 
life  is  the  age  at  whieh  the  population  at  a  given  age  will  be  redueed  one-half. 
If  of  100  children  born,  30  live  just  one  year,  20  just  five  years,  30  live  40 
years,  and  20  live  60  years,  then  the  probable  duration  of  life  of  any  one  of 
these  children  at  birth  is  five  years,  because  at  the  end  of  that  time  one-half  of 
them  will  be  dead,  but  the  expectation  of  life  of  any  one  of  these  children  is 
25.3  vears,  because  the  100  altogether  live  25,300  vears  of  life. 

If  we  have  the  results  of  a  registration  of  deaths,  but  no  information  about 
the  population,  the  best  we  can  do  is  to  compare  the  number  of  deaths  under 
one  or  under  five  years  of  age  with  the  whole  number  of  deaths,  or  the  number 
of  deaths  from  one  particular  cause  with  the  number  of  deaths  from  all  causes; 
but  the  results  are  unsatisfactory  and  may  be  very  misleading.  Suppose,  for 
instance,  that  in  a  city  1000  deaths  occur  in  a  year,  and  that  250  of  them  are 
due  to  consumption,  and  that  in  another  city  there  are  2000  deaths  in  a 
year,  of  which  500  deaths  are  due  to  consumption,  then  the  proportion  of  the 
number  of  deaths  from  phthisis  to  total  number  of  deaths  would  be  the  same 
in  the  two  cities.  But  if  the  two  cities  were  of  the  same  size,  the  liability  to 
<leath  from  phthisis  would  really  be  twice  as  great  in  the  second  city  as  it  was 
in  the  first. 

In  investigating  the  healthfulness  of  a  place  it  would  be  very  desirable  to 
know  not  only  the  number  of  deaths,  but  the  amount  and  kind  of  sickness 
which  has  prevailed.  The  usual  estimate  is,  that  for  every  case  of  death  there 
is  an  average  of  two  years'  sickness  in  a  community,  so  that  if  the  annual 
death-rate  is  18  per  1000,  the  average  number  constantly  sick  is  36.  It  is 
impossible,  however,  to  obtain  complete  and  reliable  infi)rmation  on  this  point 
from  any  city,  since  it  is,  as  a  rule,  only  collected  for  the  army  and  navy  and 
for  certain  societies.  For  certain  coiitagious  diseases,  however,  jihysicians  in 
cities  are  often  required  to  re})ort  all  cases  which  come  under  their  observation, 
these  diseases  l)eing  Asiatic  cholera,  yellow  fever,  typhus  fever,  small-pox,  scar- 
latina, and  dij)htlieria,  and  sometimes  typhoid  fever  and  measles.  The  results 
are  useful  as  far  as  they  go,  but  the  returns  are  generally  incomplete. 

Predisposing  Causes  of  Disease. 

The  most  imjiortant  jiredisposing  causes  of  disease  are  those  connecte<l  with 
the  structure  of  the  body,  being  individual  jwculiaritics  which  may  be  inherited, 
or  may  be  congenital  but  not  inherited,  or  may  be  acquired  after  birth.  In 
most  of  the  so-called  hereditary  diseases  that  which  is  transmitted  from  |):u-ent 
to  child  is  n(^t  the  disease  itself  nor  its  direct  specific  cause,  but  some  j)eeuliar- 
ity  of  structure  of  tissues  or  organs  whieh,  in  the  eoiu'se  of  development,  either 
makes  the  person  pceidiarly  susceptible  to  causes  of  disease  acting  from  without, 
or  produces  discjrder  itself  by  excess  or  defect  of  structure  or  fiinetion  of  some 
jtarticular  part.  Syphilis,  small-j)ox,  and  a  few  other  diseas(>s  m:iy  be  dir<clly 
transmitted  by  transference  of  the  specific  cause  to  the  cliild  in  itlcro.    In  scrof- 


8  HYGIEJSfE. 

I 

Ilia,  consumption,  and  other  forms  of  tuberculosis  the  specific  germ  is  very  rarely 
if  ever  transmitted,  inheritance  giving  only  a  special  susceptibility  to  its  action. 
In  gout,  rheumatism,  or  insanity  due  to  heredity  there  is  abnormal  structure  of 
some  particular  part  which  ultimately  leads  to  disease.  Heredity  transmits  im- 
munity against  certain  forms  of  disease.  Its  effects  are  seen  not  only  in  certain 
families,  but  on  the  large  scale  in  certain  races ;  thus,  the  number  of  cases  of 
cancer  in  the  white  residents  of  the  Southern  States  is  more  than  twice  as  great 
as  it  is  in  the  negroes  of  the  same  region  in  proportion  to  the  number  of  each  class, 
while,  on  the  other  hand,  the  tendency  to  tuberculosis  is  decidedly  greater  in  the 
negro  than  in  the  Avhite.  Jews  are  specially  liable  to  diabetes  and  to  various 
forms  of  degeneration  in  the  spinal  cord  in  advancing  years,  but  are  somewhat 
less  liable  to  cancer  and  consumption  than  other  whites.  In  many  cases  it  is  very 
difficult  to  distinguish  the  effects  of  inherited  bodily  peculiarities  from  those 
due  to  modes  of  life  peculiar  to  certain  families  or  races,  but  the  general  prac- 
titioner soon  learns  to  expect  certain  special  symptoms  in  the  members  of  a 
particular  family,  as,  for  instance,  delirium  in  the  course  of  fever.  In  the 
examination  of  applicants  for  life  insurance  the  family  tendency  to  death  from 
certain  forms  of  disease,  such  as  consumption,  apoplexy,  or  insanity,  is  carefully 
inquired  into,  and  is  held  to  be  of  great  practical  importance.  Persons  having 
the  same  hereditary  tendency  to  disease  should  not  intermarry,  for  the  tendency 
will  be  markedly  increased  in  their  offspring.  Persons  affected  with  hereditary 
or  well-marked  constitutional  syphilis  should  never  marry.  Every  one  has 
certain  individual  peculiarities  which  may  or  may  not  be  manifestly  inherited, 
and  it  is  in  the  detection  of  these  peculiarities,  and  in  the  estimation  of  their 
relations  to  each  other,  to  disease,  and  to  results  of  certain  remedies,  that  the 
skill  of  the  physician  largely  consists.  A  normally  w'ell-developed,  healthy 
young  man  has  more  lung  surface,  more  kidney,  or  liver,  or  lymphatic  gland, 
than  is  actually  necessary  to  preserve  life  under  ordinary  circumstances,  and 
therefore  if  a  part  of  one  of  these  organs  becomes,  through  injury  or  disease, 
unable  to  do  its  proper  work,  or  if  an  extra  amount  of  work  is  thrown  on  the 
organ  for  a  short  time,  it  does  not  necessarily  disable  him.  But  if  the  amount 
of  absorbing,  secreting,  or  excreting  surface  in  any  department  of  his  economy 
is  barely  sufficient  to  supply  the  needs  of  the  organism,  either  because  of  origi- 
nally insufficient  development  or  because  of  loss  of  a  portion  of  it  through  want 
of  exercise,  disease,  or  injury,  then  disturbances  or  excessive  demands,  which  in 
a  healthy  man  would  produce  no  noticeable  effects,  may  give  rise  to  the  most 
serious  results,  and  hence  require  special  care  in  diet,  clothing,,  and  mode  of  life 
to  maintain  comfort,  if  not  existence. 

Mental  Causes  of  Disease. 

Certain  forms  of  nervous  disease  may  be  produced  by  expectant  attention 
or  suggestion,  or,  wdiich  is  much  the  same,  by  involuntary  imitation  of  the 
symptoms  presented  by  a  person  affected  with  it.  This  occurs  in  various  forms 
of  epidemic  chorea  and  hysteria,  especially  those  occurring  under  religious 
excitement,  in  some  cases  of  staaimering,  etc.     Expectant  attention  directed  to 


MICR  O-  ORG  A  XJSMS.  9 

sonip  particular  part  or  organ  of  the  body,  especially  if  accompanied  by  strong 
belief  in  or  fear  of  some  result,  may  produce  marked  changes  in  function, 
excess  or  deficiency  of  blood-supply,  abnormal  reflexes,  and  even  permanent 
change  in  structure.  Excessive  worry  or  anxiety  is  often  a  cause  of  ilisease, 
either  by  producing  loss  of  sleep  or  by  interfering  with  the  nervous  mechanism 
regulating  the  ap})etites  and  the  action  of  the  digestive  and  secreting  organs. 
Simple  mental  exercise  in  the  form  of  study  or  writing,  even  when  carried  to 
excess,  rarely  produces  marked  ill  effects  ;  it  is  only  when  it  is  accompanied  by 
anxiety  that  its  results  are  likely  to  become  serious.  The  disorders  produced 
or  aggravated  in  children  by  school  attendance  are  more  nsually  due  to  impure 
air,  to  defective  or  improper  lighting,  and  to  badly-shaped  seats  and  desks  than 
to  excess  of  study  ;  nev'ertheless,  under  the  stimulus  of  prizes,  final  pass-exam- 
inations, etc.  the  health  of  some  sensitive  and  ambitious  children  may  be  seri- 
ously impaired,  and  such  means  of  inducing  them  to  work  should  be  used 
with  great  caution.  As  a  rule,  in  our  public  schools  too  much  is  demanded  of 
the  children,  and  the  most  of  them  have  to  do  too  much  studying  at  home  in 
order  to  keep  good  standing  in  their  classes.  In  adult  life  the  effects  of  mental 
strain  are  often  complicated  with,  or  marked  by,  those  of  such  stimulants  as 
coffee,  alcohol,  opium,  etc. ;  and  this  should  be  borne  in  mind  in  the  investi- 
gation of  such  cases. 

Micro-organisms. 

Of  the  diseases  due  to  more  or  less  preventable  causes  and  liable  to  occur 
in  epidemic  form — and  which  are  therefore  of  special  interest  from  the  hygienic 
point  of  view — the  most  important  are  those  which  are  known  or  supposed  to 
be  caused  by  very  minute  living  organisms.  These  micro-organisms  include 
the  minute  animal  forms,  or  the  microzoa  ;  the  minute  vegetable  forms,  or  the 
microphytes ;  and  also  minute  living  particles  of  protoplasm  which  may  be 
doubtfully  classed  as  distinct  organisms. 

With  regard  to  the  microzoa,  or  those  doubtful  fi)rms  known  as  the  protozoa, 
considered  as  causes  of  disease,  our  knowledge  is  as  yet  scanty.  One  form,  the 
Amoeba  djjsenterice,  is  the  cause  of  a  })eculiar  and  dangerous  form  of  dysentery  ; 
some  of  the  sporozoa  appear  to  be  comiected  with  certain  skin  diseases,  and  it 
is  i)robable  that  the  cause  of  malaria  belongs  to  this  class.  Here  also,  although 
belonging  to  higher  orders  .of  the  animal  kingdom,  may  be  mentioned  such 
parasites  as  the  Anchylostomum  duodena/c,  the  Trkhhm  .spirals,  B'dharzia  httma- 
iobia,  and  worms  of  various  kinds,  including  hydatids. 

The  microphytes  of  most  known  importance  in  the  causation  of  disease  are 
certain  kinds  of  the  schizomycetes,  commonly  known  as  bacteria,  and  especially 
those  known  as  cocci  or  micrococci,  being  minute  spherical  forms,  and  those 
named  bacilli,  which  are  rod-shaped  or  oval.  There  are  many  kinds  of  these 
i)acteria,  differing  slightly  in  shape  and  size,  and  greatly  in  the  ap|)earances 
thev  present  when  growing  in  masses  in  or  upon  various  media,  such  as  I»ccf- 
broth,  gelatin,  agar,  etc.  They  differ  also  in  the  <>ase  with  which  they  may  be 
stained  with  different  substances,  in  the  tenacity  witli  which  (hey  ret^iin  these 


10  HYGIENE, 

stains,  in  the  decompositions  and  decomposition-products  which  they  produce, 
and  in  the  effects  which  follow  their  entrance  into  the  living  human  body. 
These  differences  are  constant  and  each  kind  breeds  true,  so  that  we  may  say 
that  there  are  many  distinct  species.  The  great  majority  of  the  species  are  not 
only  harmless  so  far  as  man  is  concerned,  but  beneficial.  They  feed  upon  dead, 
insoluble  organic  matters,  the  products  of  higher  animal  and  vegetable  life,  and 
convert  them  into  soluble  forms  of  simpler  composition  which  may  be  utilized 
by  living  plants.  They  are  present  in  the  lower  layers  of  air  over  the  land 
except  in  the  Polar  regions,  in  the  upper  layers  of  soil,  and  in  almost  all  water, 
and  there  is  very  little  dead  organic  matter  which  escapes  them.  Almost  all 
forms  of  putrefaction  and  fermentation  are  produced  by  them.  They  multiply 
by  simple  division  with  great  rapidity  under  favorable  circumstances,  some  of 
them  dividing  once  every  half  hour,  so  that  a  single  cell  may  produce  ten  mil- 
lions or  more  in  twenty-four  hours.  They  are  about  one-twenty-five-thousandth 
of  an  inch  in  diameter,  and  from  one-fifteen-thousandth  to  one-five-thousandth 
of  an  inch  in  length.  It  would  require  about  twelve  million  micrococci  placed 
side  by  side  to  cover  an  ordinary  pin's  head.  All  of  them  require  the  presence 
of  moisture,  nitrogen  compounds,  usually  in  the  form  of  dead  organic  matter, 
and  of  a  suitable  temperature  to  enable  them  to  grow  and  develop.  A  few  of 
them  produce  disease  in  man,  either  directly  or  through  their  products.  The 
proof  that  a  particular  form  of  disease  is  due  to  a  particular  micro-organism 
is  as  follows  : 

1.  The  disease  must  be  one  that  can  be  identified — that  is,  that  jiresents  a 
tolerably  distinct  series  of  symptoms  or  of  pathological  results — so  that  it  can 
be  distinguished  from  other  diseases  either  in  the  living  or  the  dead  subject,  or 
in  both. 

2.  In  all  cases  of  the  disease  the  specific  form  of  the  micro-organism  must 
be  found  in  the  fluids  or  tissues  of  the  body. 

3.  This  micro-organism  must  be  separated  from  the  fluids  or  tissues  of  the 
body,  and  from  other  micro-organisms,  and  cultivated  in  suitable  media  outside 
the  animal  body  until  a  series  of  pure  cultures  is  thus  obtained. 

4.  The  pure  culture  thus  obtained  must  produce  the  specific  disease  in  a 
healthy  animal  when  introduced  into  its  body  by  inoculation  or  through  the 
alimentary  canal  or  air-passages. 

5.  In  the  animal  in  which  the  disease  has  thus  been  produced  the  same 
micro-organism  must  be  found. 

Since  many  different  micro-organisms  may  be  found  at  different  times  in  the 
human  body,  including  all  the  varieties  found  in  water  and  air,  the  mere  occa- 
sional coincidence  of  the  presence  of  some  one  form  in  a  ])articular  disease  is 
not  sufficient  to  prove  a  causal  connection.  It  must  also  be  remembered  that 
the  specific  micro-organisms  may  be  present  in  or  on  the  skin  or  mucous  mem- 
branes of  the  body  without  producing  disease,  for  in  many  cases  they  require 
special  conditions  of  injury  or  lowered  vitality  of  the  tissues  with  which  they 
come  in  contact  to  enable  them  to  develop,  and  in  some  persons  they  produce  no 
effects,  as  will  be  explained  hereafter  in  speaking  of  immunity.    As  inoculations 


Midi  O-  O  R  a  A  XISMS.  1 1 

of  disease-producing  organisms,  or  of  those  supposed  to  be  such,  cannot,  as  a  rule, 
be  tried  on  man,  the  chain  of  positive  experimental  proof  can  usually  only  be 
completed  for  those  diseases  which  can  be  produced  in  other  animals  ;  neverthe- 
less, a  high  degree  of  probability  may  be  obtained  when  a  i)articular  form  of 
micro-organism  is  always  found  j)rcsent  in  a  person  atfccted  with  a  disease  hav- 
ing well-marhed  characteristics,  and  is  seldom  or  never  found  in  the  living  body 
when  such  disease  is  not,  or  has  not  recently  been,  present. 

No  satisfactory  classification  of  the  bacteria  has  yet  been  made.  For  the 
purposes  of  this  article  it  is  sufficient  to  say  that  the  spherical  forms,  or  micro- 
cocci, include  Streptococcus,  in  which  the  individual  cocci  after  subdivision 
remain  united  together  in  little  chains  or  strings  ;  Staphylococcus,  in  whi(;h  they 
are  clustered  together  like  a  bunch  of  grapes  ;  and  Micrococcus,  in  which  the 
granules  are  usually  seen  singly  or  in  pairs  or  in  short  chains.  When  they 
are  usually  in  pairs  they  are  called  diplococci.  Some  authors  use  the  term 
micrococcus  as  the  generic  name  of  all  forms ;  thus,  the  Micrococcus  pyogenes 
aureus  is  the  same  as  the  Staphylococcus  pyogenes  (uireus.  Of  the  rotl-shaped 
forms,  some  authors  refer  to  a  separate  genus,  Bacterium,  all  those  in  which 
spore-formation  is  absent  or  unknown,  but  most  writers  include  them  all  under 
th^  term  Bacillus  ;  thus  the  Bacterium  prodigiosum  is  the  same  as  the  Bacillus 
prodigiosus. 

The  student  should  bear  in  mind  that  there  is  no  sharp  dividing-line  between 
the  coccus  forms  and  the  rod-shaped  forms;  that  very  short  rods  with  rounded 
ends  or  shaped  like  an  ellipse  are  called  micrococcus  by  one  observer  and  bacil- 
lus or  bacteriimi  by  another;  and  that  the  same  organisms  in  different  stages  of 
growth  and  development  may  show  single  cocci,  chains,  and  rods.  The  spirally- 
twisted  forms  of  bacteria  are  classed  as  Spirillum,  but  the  sj)irillum  of  Asiatic 
cholera  is  commonly  called  the  cholera  bacillus.  The  following  is  a  list  of  the 
principal  diseases  of  man  which  are  due  to  bacteria,  with  t\\o  usual  names  of  the 
species  of  bacteria  which  cause  them  : 

1.  Inflammation  of  tissues,  producing  suj>puratiou  ami  its  cohscquenccs,  as 
in  abscesses,  boils,  pyaemia,  osteomyelitis,  ])uerpcral  fever,  etc.  These  are  pro- 
duced by  the  Staphylococcus  pyogenes  aureus,  the  Staphylococcus  pyogenes  dtreus, 
the  Staphylococcus  pyogenes  albus,  the  Streptococcus  pyogenes,  and  by  a  few  other 
forms,  the  whole  forming  a  group  known  as  the  pyogenic  micrococci.  Two  or 
more  kinds  of  these  are  often  found  together  in  pus.  The  specific  cause  of 
erysipelas  also  belongs  to  this  group. 

2.  Gonorrho-a,  pn)du(;cd  by  the  Merisniopedia  gonorrhoea  or  gonococcus. 

3.  Anthrax,  caused  by  the  Bacillus  aufhrads. 

4.  Tuberculosis,  caused  by  the  Bacillus  tuberculosis. 

5.  Leprosy,  caused  by  the  Bacillus  lejtr(v. 
G.  Glanders,  caused  by  the  Ilacillux  vudlri. 

7.  Typhoid  fi;vcr,  caused  by  the  fiacillus  typhosus. 

8.  I)ij)lithcria,  caused  by  the  liacillux  diphtheria:. 

9.  Tetanus,  cause<l  by  tlie  bacillus  of  tetanus. 

10.  Specific;  croupous  pneumonia,  caused  by  tlu;  Diplococcus  pneumoniw. 


12  HYGIENE. 

11.  Asiatic  cholera,  caused  by  the  cholera  bacillus. 

12.  Relapsing  fever,  caused  by  the  Spirochcete  Obermeierii. 

In  addition  to  these  there  are  various  forms  of  dysentery,  of  so-called  cholera 
morbus,  cholera  infantum  and  summer  diarrhoea  of  infants,  and  of  chronic  forms 
of  diarrhoea  which  are  probably  produced  by  one  or  more  species  of  bacteria,  as 
are  also  various  forms  of  endemic  tropical  ulcer,  such  as  the  Delhi  boil,  and  of 
skin  disease,  such  as  rhinoscleroma.  There  are  also  a  number  that  produce 
specific  diseases  in  certain  animals,  but  which  have  thus  far  been  very  rarely  or 
never  observed  in  man,  such  as  the  bacillus  of  hog  cholera,  of  swine  erysipelas, 
of  malignant  oedema,  of  black  leg  of  cattle,  the  vibrio  of  Metschnikoff,  etc.  It 
is  also  probable  that  small-pox,  measles,  scarlatina,  yellow  fever,  typhus  fever, 
influenza,  Oriental  plague,  and  syphilis  are  due  to  specific  micro-organisms,  but 
this  is  not  yet  demonstrated.  Some  of  the  specific  pathogenic  micro-organisms, 
such  as  those  of  diphtheria,  typhoid  fever,  and  cholera,  may  grow  and  multiply 
in  dead  organic  matter  of  animal  origin  at  the  ordinary  temperatures  of  the  air, 
and  hence  collections  of  such  organic  matter  may  become  dangerous  centres  of 
infection.  Others,  like  those  of  tuberculosis,  of  glanders,  and  probably  also  of 
small-pox,  measles,  scarlatina,  etc.,  do  not  grow  and  multiply  outside  the  living 
animal  bodv  under  ordinarv  circumstances,  so  far  as  we  now  know,  being  what 
are  termed  obligatory  parasites.  Many  different  kinds  of  bacteria  are  found  on 
the  surface  of  the  human  body,  in  the  mouth  and  air-passages,  and  in  the  ali- 
mentary canal.  A  few  exist  in  the  hair-follicles  beneath  the  epidermis,  and 
among  these  are  some  of  those  wiiich  cause  suppuration  under  favorable  cir- 
cumstances. They  gain  admission  to  the  body  through  the  air  and  in  articles 
of  food  and  drink.  The  bacteria  of  the  air  come  from  the  upper  layers  of  the 
soil,  from  hay,  straw,  clothing;  in  short,  from  whatever  produces  dust,  to  the 
particles  of  which  they  are  usually  found  adherent.  They  are  not  detached  into 
the  air  by  simple  evaporation  from  moist  surfiices.  The  air  expired  in  respira- 
tion does  not  contain  them  unless  there  is  coughing  or  sneezing,  in  which  case 
they  may  be  in  the  spray.  An  open  tubful  of  diphtheritic  membranes  or  of 
typhoid  stools  will  give  off  no  specific  germs  to  the  air  so  long  as  its  contents  are 
kept  thoroughly  moist  and  no  bubbles  arise  to  break  into  spray  and  throw  par- 
ticles of  liquid  into  the  air.  Sewer  air  contains  fewer  bacteria  than  outside  air, 
and  those  found  in  sewers  do  not,  as  a  rule,  come  from  the  sewage,  but  are 
brought  in  in  air-currents  from  the  outside.  Whatever  produces  dust  increases 
the  number  of  ba(;teria  in  the  air,  as,  for  example,  dry  sweeping,  bed-making, 
stamping  of  feet  in  assembly  halls,  etc.  The  fact  that  disease-producing  organ- 
isms cannot  escape  into  the  air  from  the  surface  of  still  fluids  or  from  thoroughly 
moist  surfaces  is  one  of  great  practical  importance  in  hygiene,  and  will  be 
referred  to  hereafter  in  speaking  of  disinfection,  of  ventilation,  and  of  house- 
drainage.  The  number  of  bacteria  in  the  upper  layer  of  the  soil  is  very  great, 
the  most  important  disease-producing  forms  found  there  being  the  bacilli  of 
malignant  oedema  and  of  tetanus,  and  in  cities  those  which  produce  summer 
diarrhoea.  The  soil-organisms  which  are  of  the  greatest  importance  in  decom- 
posing organic  matters  are  those  which  produce  nitrites  and  nitrates,  and  are 


IMMUNITY.  13 

known  as  the  nitrifying  bacilli,  and  the  action  of  these  in  the  pnrification  of 
waters  contaminated  by  organic  matters  is  of  great  practical  interest.  The 
chemical  componnds  produced  or  excreted  by  many  bacteria  check  the  growth, 
or  even  tlcstroy  the  vitality,  of  other  forms,  and  especially  of  the  disease- 
producing  forms ;  while,  on  the  other  hand,  the  power  of  certain  bacteria  to 
produce  disease  is  greatly  increased  by  the  presence  of  other  forms  which 
by  themselves  appear  to  have  no  harmful  influence.  The  means  at  our  dis- 
posal for  preventing  the  diseases  caused  by  micro-organisms  consist  of  the 
production  of  immunity  in  individuals,  of  disinfection,  and  of  isolation. 

Immunity. 

A  person  is  said  to  possess  immunity  as  regards  a  certain  disease  when  he 
is  but  slightly  or  not  at  all  affected  by  the  causes  of  that  disease  when  brought 
into  contact  with  them.  Immunity  may  be  natural  or  artificial,  partial  or 
complete,  relative  or  absolute.  Natural  immunity  may  be  hereditary ;  as,  for 
example,  in  the  comparative  insusceptibility  of  the  negro  to  malarial  and  yel- 
low fevers.  Artificial  or  acquired  immunity  may  be  produced  by  the  action 
of  the  disease  itself.  Thus,  a  person  who  has  recovered  from  an  attack  of 
small-pox,  scarlet  fever,  measles,  whooping  cough,  typhoid  fever,  or  yellow 
fever  is  more  or  less  immune  against  a  second  attack  of  that  disease,  and  one 
who  has  been  properly  vaccinated  is  immune  against  small-pox.  Precisely 
how  this  immunity  is  produced  we  do  not  know,  and  it  probably  differs  some- 
what in  different  diseases,  but  in  general  it  may  be  said  to  be  due  to  the 
presence  of  certain  albuminoid  substances  which  have  the  power  of  killing 
or  weakening  pathogenic  micro-organisms  or  of  neutralizing  their  toxic  prod- 
nets ;  and  this  presence  is  probably  connected  with  peculiarities  in  the  mode 
of  life  and  chemical  products  of  large  masses  of  cells  in  the  body.  In  some 
cases  these  masses  may  perhaps  be  definitely  localiz'xl,  forming  a  sort  of  new 
organ  with  specific  powers,  as,  for  example,  in  the  lotuility  in  which  vaccina- 
tion has  been  performed.  Cases  arc  known  in  which  amputation  of  the 
vaccinated   limb   has  seemed   to  destroy   the  imnnniity   against  small-pox. 

Immunity  is  rarely  absolute  and  complete;  second  and  even  third  attacks 
of  all  the  diseases  named  above  may  occur,  but  from  experiments  on  animals 
it  is  probable  that  it  requires  the  concurrent  action  of  a  much  larger  number  of 
the  specific  organisms  to  j)roduce  a  second  attack  than  it  did  for  the  fii-st.  The 
natural  fluids  and  living  tissues  of  the  body,  when  healthy,  have  the  power 
of  destroying  a  certain  limited  number  of  micro-organisms ;  thus,  almost 
every  one  at  some  time  or  other  inhales  the  bacilli  of  tubercle,  yet  in  only 
a  certain  number  do  they  develop  and  nitdliply.  At  present,  vaccination  for 
small-pox  is  the  only  operation  for  j)ro(lucing  iiiitinmity  in  man  which  is 
advised  by  physicians,  but  it  is  probable  that  this  metliod  ol"  pro|thyI;ixis  may 
be  extended  in  the  future.  It  is  important  to  bear  in  mind  tiic  ellccts  of 
immunitv  in  investiiratin";  the  conditions  of  outbreaks  of  disca.se  in  certain 
]o(;alities  ;  for  in.stance,  yellow  fever  is  not  likely  to  Ixcoiiie  <  pideiuic  in  cert^iin 
old  parts  of  cities  .specially  liable  to  be  affectx'd  by  it,  simply  becau.se  almost  every 


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15 


inhabitant  of  those  quarters  has  had  the  disease;  and  in  like  manner  after  an 
epidemic  of  typhoid  has  swept  through  a  village  a  large  number  of  the  sur- 
vivors will  be  immune  against  that  disease.  Immunity  thus  produced  is  the 
cause  of  the  ajipearance  of  certain  contagious  diseases  in  epidemics  at  tolerably 
regular  intervals,  as  small-pox  before  vaccination  was  introduced  used  to  be 
epidemic  at  intervals  of  five  or  six  years,  and  scarlet  fever  now  appears  in 
somewhat  similar  waves.  It  requires  about  that  length  of  time  for  a  new 
generation  of  children  who  are  epinosic — that  is,  susceptible  to  the  specific 
germ — to  be  developed  in  order  to  furnish  sufficient  material  for  an  epidemic. 
This  is  shown  diagrammatically  in  Figs.  1  and  2. 

Fig.  2. 


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2. 

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11  - 
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9  . 

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Liiagram  showing 'percentage  of  deaths  from  Scarlet  Fever  in  total  deaths  in  Providence,  K.  1.,  lor 

forty-nine  years. 


Disinfection. 

Sterilization  of  a  substance,  or  of  a  flask  or  other  vessel,  consists  in  the  kill- 
ing of  all  living  organisms  containal  in  it.  It  may  be  partial  or  total,  relative 
or  absolute,  permanent  or  temporary.  In  experiments  in  cultivating  bacteria 
the  culture  media  and  the  vessels  which  contain  them  are  usually  totally  and 
absolutely  sterilized,  but  it  is  not  desired  that  this  sterilization  shall  be  perma- 
nent under  all  conditions.  It  is  to  be  temporary,  and  to  endure  only  until  we 
inoculate  the  media  with  some  particular  form  of  organism  which  wc  wish  to 
grow  there.  Total  perrtianent  sterilization  is  rarely  used  unless  wc  wish  to 
entirely  decompose  and  destroy  the  substance,  as  by  fire.  The  :i])plication  of 
sterilization  to  the  destruction  of  those  micro-organisms  wliich  cause  s|)ccifi(! 
infectious  or  contagious  diseases  is  called  <lisinfcctiou,  and  (he  agents  u.^^ed  for 
this  purpose  are  called  disinfectants  or  germicides.  In  popular  language  the 
word  "disinfe<;tion"  is  also  a|)plied  to  i)rocesses  intended  <(.  destroy  inli'ction 
if  it  be  present.  Thus  we  speak  of  the  disinfection  of  a  piivy-vaidt,  of  sewage, 
etc.,  and  there  is  no  sjx'cial  objection  to  this  u.>^eof  the  word,  for  in  the  inajoiity 
of  cases  in  which  we  use  disinfeetanls  \\^^  do  not  know  |.ositively  (hat  s|»eei(i<; 
disease- producing  germs  are  present,  Iml    ninciy  think    it    proI)able  that    tiny 


16  HYGIENE. 

mav  be  there.  Disinfection  may  often  be  obtained  without  complete  steril- 
ization. This  is  due  to  the  fact  that  most  micro-organisms  which  are  rapidly 
growing  and  multiplying  in  moist  media,  including  most  of  the  micrococci  and 
the  bacilli  of  cholera,  typhoid,  and  dysentery,  are  much  more  easy  to  kill  than 
are  the  spores  of  certain  forms,  especially  of  the  hay  bacillus  and  of  the  bacillus 
of  anthrax.  In  comi)aring  the  effects  and  efficiency  of  various  disinfectants 
time  is  a  most  important  element,  for  a  degree  of  heat  or  a  chemical  solution 
which  will  have  no  eifect  in  five  minutes  and  very  little  in  half  an  hour  may 
effectually  destroy  the  vitality  of  the  organisms  in  twenty-four  hours. 

Antiseptics  are  substances  which  prevent  the  growth  and  development  of 
micro-organisms,  and  especially  of  those  which  cause  fermentation  or  putrefac- 
tion or  which  produce  suppuration.  They  may  or  may  not  be  disinfectants  or 
germicides.  A  universal  germicide — that  is,  an  agent  which  effects  complete 
sterilization — is  necessarily  an  antiseptic  for  the  time  being,  but  if  meat  broth 
be  heated  until  it  is  sterilized  and  is  then  left  in  an  open  vessel,  it  is  not 
thereby  made  antiseptic.  An  antiseptic  is  something  which  remains,  and  pre- 
vents the  development  not  only  of  the  bacteria  present,  but  of  those  which  may 
be  added  afterward,  although  it  does  not  necessarily  kill  them.  A  deodorant  is 
an  agent  which  destroys  or  mitigates  foul  and  unpleasant  odors,  but  many  of 
these  agents  have  little  or  no  disinfectant  powers.  There  is  no  definite  relation 
between  foul  odors  and  specific  disease-producing  organisms :  either  may  be 
present  without  the  other,  and  it  is  improper  to  speak  of  the  process  of  mask- 
ing or  destroying  the  odor  produced  by  a  uterine  cancer  in  the  last  stages  as 
being  a  process  of  disinfection. 

The  principal  agents  now  used  for  disinfection  are  heat,  carbolic  acid, 
bichloride  of  mercury,  chloride  of  lime,  quicklime,  alcohol,  and  sulphurous 
acid.  These  are  the  cheapest,  the  most  generally  applicable,  and  the  least 
likely  to  damage  clothing,  furniture,  etc.  The  strong  mineral  acids,  chloride 
of  zinc,  chlorine,  hypochlorite  of  soda,  and  certain  coal-tar  products  are  also 
good  disinfectants,  but  are  only  used  in  special  cases.  What  may  be  called  the 
natural  process  of  disinfection  is  accomplished  in  the  course  of  time  by  light, 
fresh  air,  and  the  action  of  the  common  bacteria.  All  of  these  are  of  the 
greatest  practical  importance  in'  preventing  the  undue  increase  of  pathogenic 
organisms  and  in  aiding  in  their  destruction  in  water,  soil,  and  air,  and  should 
be  constantly  employed  as  auxiliaries;  but  for  prompt  and  certain  disinfection 
we  must  resort  to  other  agents.  The  practical  utility  of  these  depends  not  only 
on  their  germicidal  powers,  but  on  the  ease  with  which  they  can  be  applied, 
their  cost,  and  the  danger  of  injury  to  persons  or  property  from  their  use. 

The  most  important  of  these  special  disinfecting  agents  is  heat,  and  the 
simplest  method  of  applying  it  in  many  cases  is  to  burn  the  infected  article. 
Sometimes  it  is  best  to  do  this  for  the  moral  effect,  to  reassure  the  community, 
as,  for  example,  to  burn  up  an  old  small-pox  hospital  instead  of  tearing  it 
down.  The  cremation  of  garbage,  of  dead  animals,  or  of  human  bodies  is 
a  disinfecting  process,  though  not  usually  performed  for  that  purpose.  Dry 
heat — that  is,  a  sort  of  baking  in  a  closed  chamber  or  oven — has  been  used  to 


DISIXFECTIOX.  1 7 

a  considerable  extent  in  many  places  for  the  disinfection  of  clothing,  bedding, 
and  small  movable  articles,  bnt  is  now  being  abandoned  except  for  laboratory 
purposes  and  for  the  sterilization  of  some  surgical  instruments.  It  penetrates 
very  slowly  into  non-conducting  articles,  such  as  bed<ling,  mattresses,  and  pil- 
lows ;  it  is  very  difficult  to  regulate  so  as  to  secure  a  proper  temperature  in  all 
parts  of  the  oven  ;  it  fixes  stains  of  blood,  excreta,  etc.  in  clothing  and  bedding 
so  that  they  cannot  be  washed  out ;  and  it  is  very  liable  to  injure  the  texture 
of  Moven  stuffs,  scorching  woollen  at  about  250°  F.  Exposure  to  hot  air  at 
220°  F.  for  one  hour  will  kill  micrococci  and  bacilli,  but  not  spores,  which, 
however,  may  be  killed  by  five  hours'  exposure  to  this  temperature.  One 
hour's  exposure  to  a  dry  heat  of  245°  F.  will  kill  the  spores. 

Heat  combined  with  moisture  destroys  the  life  of  micro-organisms  at  lower 
temperatures  with  the  same  time  of  exposure,  or  witii  much  less  time  of 
exposure  at  the  same  temperatures,  than  dry  heat,  and  is  therefore  less  liable 
to  injure  the  articles  subjected  to  it.  The  simplest  form  of  application  is  by 
boiling  in  water,  and  this  is  the  best  method  of  disinfecting  all  articles  of 
clothing,  bedding,  towels,  etc.  which  can  be  washed  without  injury.  The 
experience  of  large  public  laundries,  and  especially  of  laundries  connected  with 
hospitals  for  infectious  diseases,  such  as  that  in  Glasgow,  shows  that  all  germs 
of  infectious  disease  are  thus  destroyed,  and  that  clothing  of  small-pox,  tyj>lins, 
and  other  patients  may  be  mingled  and  go  through  the  boiling-vats  without 
risk  to  the  subsequent  wearers.  It  should  be  borne  in  mind  that  infected 
clothing  and  bedding  is  chiefly  dangerous  when  it  is  dry.  When  it  is  soaked 
with  water  it  does  not  give  oif  germs  to  the  air.  It  would  often  be  best,  in 
collecting  clothing  and  bedding  supposed  to  be  infected,  to  place  the  articles  at 
once  in  a  cask  or  tub  or  other  vessel  containing  cold  water,  partly  to  soak  out 
any  stains  and  partly  to  prevent  the  giving  oif  of  any  dangerous  dust.  It  is 
usually  advised  tiiat  the  clothing  of  the  sick,  and  especially  of  those  in  hos- 
pitals for  infectious  diseases,  should  be  washed  in  a  place  entirely  separated 
from  that  in  which  other  clothing,  such  as  that  of  nurses  and  attendants,  is 
washed  ;  but  while  this  may  be  desirable  as  a  matter  of  sentiment  and  imagina- 
tion, it  is  not  necessary,  for  half  an  hour's  boiling  makes  all  the  stuffs  harm- 
less. Boilino-  is  also  an  effectual  means  of  destroving  choleraic,  tvi)hoid,  or 
dysentery  germs  in  water  which  must  be  used  for  drinking,  and  it  is  a  good 
method  of  sterilizing  sin-gical  instruments  that  arc  properly  constructed  with 
reference  to  this  mode  of  treatment.  Moist  heat  may  also  be  applied  by  means 
of  steam  in  boxes  or  chambers  s|)ecially  constructed  for  the  purpose.  To  obtain 
satisfactorv  results,  all  air  should  be  driven  out,  and  the  steam  should  be  moist 
or  saturated  at  a  temperature  of  about  220°  F.  If  the  pressure  is  less  than 
that  ])ertaining  to  the  temperatures  as  given  by  Regnault's  law,  the  steam  is 
superheated,  and  is  little  better  th:m  hot  air  f.r  (lisinfc(;ting  piu'poses,  while  if 
the  pressure  is  greater  than  that  pertaining  to  the  temperature,  there  is  aduiix- 
ture  of  air,  and  the  clothing,  etc.  are  not  properly  i)cnetratcd.  Tlic  pressin-e 
should  only  be  great  enough  to  secure  that  there  shall  be  no  condensation  of 
moisture  in  the  chamber.     Many  forms  of  steam  di-iiiCceting  apparatus,  butli 

Vol..  I.— 2 


18  HYGIENE. 

fixed  and  movable  and  of  various  sizes,  are  now  constructed  by  English, 
French,  and  German  manufacturers.  In  judging  of  the  merits  of  any  par- 
ticular form  or  in  devising  a  new  one  the  following  points  should  be  borne  in 
mind  :  A  constant  and  uniform  temperature  should  be  secured  throughout  the 
chamber  and  in  the  interior  of  the  naattresses,  rolls  of  bedding,  etc.  to  be  dis- 
infected. To  ensure  this,  a  metallic  thermometer  with  electric  connections 
with  a  small  gong  should  be  placed  free  in  the  chamber,  so  arranged  that 
Avhen  the  temperature  reaches  221°  F.  (105°  C.)  the  gong  will  sound;  and  a 
similar  thermometer,  similarly  connected  and  adjusted,  should  be  placed  in  the 
<;entre  of  the  most  bulky  article  to  be  disinfected,  such  as  a  mattress  or  pillow. 
Mercurial  thermometers  are  not  as  serviceable  for  this  purpose  as  those  made 
of  a  coiled  strip  of  metal  which  make  the  electric  connection  by  expansion  and 
contact.  The  steam  should  flow  through  the  chamber  freely  at  first,  until  the 
greater  part  of  the  air  is  expelled  ;  and  this  seems  to  be  best  eifected  in  those 
forms  of  apparatus  in  which  the  steam  is  admitted  to  the  top  of  the  chamber, 
the  outlet  being  at  the  bottom  and  so  controlled  by  a  valve  as  to  secure  the 
amount  of  pressure  required.  After  the  greater  part  of  the  air  of  the  chamber 
has  been  expelled,  the  valve  may  be  closed  and  the  pressure  and  temperature 
allowed  to  rise  until  the  gong  indicates  that  the  temperature  of  105°  C.  has 
been  reached  in  the  chamber.  The  valve  should  then  be  opened  again,  and 
the  pressure  be  made  to  vary,  for  the  purpose  of  expelling  the  air  from  the 
interior  of  the  mattresses,  etc.,  until  the  enclosed  thermometer  rises  to  105°  C, 
as  indicated  by  its  gong.  When  this  has  been  secured  the  valve  should  be  so 
set  as  to  maintain  this  temperature  and  pressure  for  about  forty  minutes,  which 
will  be  sufficient  to  secure  complete  disinfection.  The  chamber  itself  is  usually 
made  of  boiler  iron  with  double  walls,  and,  if  it  is  a  fixture  in  a  central  disin- 
fecting establishment,  it  has  a  door  at  each  end,  and  is  set  in  a  partition  wall  in 
such  a  way  that  the  articles  to  be  disinfected  are  introduced  at  one  door  and 
removed  from  the  other,  so  that  thev  do  not  come  out  into  a  room  which  has 
contained  infected  articles.  The  central  disinfecting  stations  of  Berlin  and  of 
Paris  may  be  taken  as  types  of  the  arrangement  which  is  desirable.  Where 
the  apparatus  is  in  constant  daily  use  it  may  have  its  own  boiler ;  where  it  is 
only  used  occasionally  it  will  be  better  to  obtain  the  steam  from  some  plant 
which  is  in  daily  use,  for  the  articles  to  be  disinfected  should  not  be  allowed 
to  accunudate,  but  should  be  promptly  treated.  It  must  be  borne  in  mind  in 
operating  a  public  disinfecting  station  that  the  results  will  be  judged  by  house- 
keepers with  reference  to  the  effects  upon  color,  size,  and  texture  of  the  articles 
submitted  to  the  process.  As  Dr.  Russell  remarks,  it  is  of  no  use  to  quote 
sci(!ntific  authorities  to  the  woman  who  finds  that  her  blankets  come  back  a 
sliade  yellower  than  they  were  when  she  sent  them  to  the  station.  "  Dynamo- 
metric  experiments  on  the  breaking-point  of  hair-fibres  will  be  of  little  use 
against  a  claim  for  damages  which  is  supported  by  the  fact  that  the  upholsterer 
has  charged  so  nuich  for  the  wool  or  hair  necessary  to  make  up  the  original 
weight  of  the  mattress  or  pillow.  The  result  is,  that  there  is  constant  friction 
in  carrying  out  disinfection  on  a  large  scale.     There  is  a  temptation  to  the 


J)J>SJA'FJ'J('TIOX.  19 

officials  to  scamp  the  work  to  avoid  censure,  and  tliere  are  constant  private 
efforts  to  escape  interference  by  concealment  or  appeal  to  domestic  processes." 

The  chemical  disinfectants  jnay  be  divided  into  those  which  are  used  in 
gaseous  and  those  which  are  used  in  liquid  forms.  Of  the  gaseous  disinfectants, 
sulphurous  acid  is  the  one  chiefly  employed,  and  next  to  this  comes  chlorine. 
Nitrous-acid  fumes  and  hydrochloric-acid  fumes  have  also  considerable  disin- 
fecting powers,  but  ar'fe  very  rarely  used.  Attempts  to  disinfect  the  air  sur- 
rounding a  patient  are  useless.  It  may  to  a  certain  extent  be  deodorized  or  be 
given  some  special  odor,  as  by  the  use  of  saucers  containing  chloride  of  lime 
placed  about  the  room,  or  of  strips  of  cloth  soaked  in  carbolic  acid,  or  by  burn- 
ing pastilles  of  various  kinds;  but  all  these  things,  so  far  as  disinfection  is  con- 
cerned, are  what  Simon  calls  "a  futile  ceremony  of  vague  chemical  libations  »»r 
powderings,  savoring  rather  of  superstitious  observance  than  of  science."  Theo- 
retically, it  is  possible  to  disinfect  air  by  passing  it  over  highly-heated  surfaces 
or  by  drawing  it  through  cotton  filters,  but  these  processes  are  only  used  on  a 
small  scale  in  the  laboratorv. 

"We  cannot  conveniently  apply  heat  to  the  walls,  floors,  and  surfaces  of 
rooms,  to  certain  kinds  of  furniture,  etc.,  and  for  this  purpose  it  has  been  usual 
to  employ  the  fumes  of  burning  sul})hur — a  very  old  process,  for  Homer  tells 
in  the  Odyssey  that  Ulysses  purified  his  house  in  this  way.  The  advantages  of 
sulphurous  acid  are  that  it  is  extremely  diffusible,  so  that  it  will  readily  pene- 
trate into  the  interior  of  a  mattress  or  pillow  or  the  upholstery  of  a  chair  ;  it 
has  little  or  no  injurious  effects  on  the  ordinary  furniture  of  ai>artraents ;  it  is 
easy  to  use  and  is  cheap.  It  will  not  destroy  spores,  and  is  therefore  useless  in 
disinfecting  for  anthrax  and  tuberculosis,  and  it  escapes  so  rapidly  from  ordi- 
nary rooms  that  it  is  very  difficult  to  keep  a  sufficient  strength  of  it  in  the  air 
for  a  sufficient  length  of  time  to  produce  certain  germicidal  results.  It  should 
not  be  relied  upon  as  the  exclusive  means  of  disinfecting  an  aj)artment,  but 
may  be  applied  after  the  application  of  liquid  and  cleansing  disinfectants  to  all 
surfaces  as  far  as  possible.  In  most  cases  it  is  applied  by  burning  sulj)hur  in 
an  iron  vessel  placed  on  sand  in  the  room  Avhich  it  is  desired  to  disinfect.  The 
quantity  necessary  is  about  sixty  grammes  per  cubic  metre,  and  it  is  difficult  to 
secure  complete  combustion  of  this  amount  if  the  room  be  sufficiently  air-tight 
to  secure  useful  results.  It  is  used  in  France  and  in  New  York,  but  has  been 
abandoned  in  Germany.  Its  efficacy  is  increased  by  the  presence  of  moisture 
in  the  air.  For  cleansing  walls,  woodwork,  floors,  etc,  in  a  room  presumed  to 
be  infected  rubbing  with  bread-crumb,  as  recommended  by  Esmarch,  is  a  good 
method.  The  crumbs  should  be  ke])t  moist,  carefully  collected,  and  |>i(uiiptly 
l)urncd.  Ilnbbino;  with  old  (•l(»tlis  wet  with  an  acid  sohilinii  of  corrosive  sub- 
liraate  is  also  a  good  methotl.  All  mere  rubbing  and  scrul)i)ing  nicfliods,  how- 
ever, can  effect  only  j)artial  disinfection  in  the  habitations  of  (lie  pdor,  Itccause 
of  the  niunber  of  fissures  and  cnicks  in  the  walls,  ceilings,  and  floors,  i\u-  interior 
of  which  cannot  be  reached  in  this  way. 

Of  liquid  disinfectants  one  of  the  most  useful  is  a  solution  of  corrosive  sub- 
limate acidified  with  hvdn.rhloric  or  tartaric  acid.    That  used  in  the  Paris  dis- 


20  HYGIENE. 

infection  service  is  composed  of  corrosive  sublimate  2  grammes,  tartaric  acid 
24  grammes,  water  1  litre,  with  5  drops  of  a  5  per  cent,  solution  of  carrainate 
of  indigo.  That  most  used  in  England  is  corrosive  sublimate  |  ounce,  hydro- 
chloric acid  1  ounce,  water  3  gallons,  tinted  with  5  grains  of  aniline  blue.  That 
recommended  by  the  Committee  on  Disinfectants  of  the  American  Public 
Health  Association  consists  of  2  drachms  each  of  corrosive  sublimate  and  per- 
manganate of  potash  to  the  gallon  of  water.  Of  thes/e  the  first  is  the  least 
likely  to  stain  or  injure  the  articles  to  which  it  is  applied,  which  should  be  those 
that  cannot  be  subjected  to  dry  or  moist  heat,  including  articles  made  wholly  or 
in  part  of  leather,  rubber,  fur,  or  pasteboard.  It  is  also  used  for  moistening 
cloths  for  wiping  floors  or  woodwork  of  rooms.  Corrosive  sublimate  is  not  a 
good  disinfectant  for  sputa  or  faeces,  as  it  forms  an  insoluble  compound  with 
albumins.  For  these  matters  a  solution  of  chloride  of  lime,  4  ounces  to  the 
gallon  of  water,  is  the  best,  provided  the  chloride  of  lime  contains  at  least  25 
per  cent,  of  available  chlorine.  An  infectious  stool  from  a  typhoid,  cholera,  or 
dysentery  patient  cannot  be  disinfected  by  pouring  a  little  strong  disinfecting 
solution  on  it,  shaking  it  around  a  little,  and  then  emptying  the  vessel.  About 
a  quart  of  the  solution  employed  should  be  placed  in  the  vessel  in  which  the 
stool  is  discharged,  and  the  mixture  should  remain  in  the  vessel  at  least  three 
hours  before  it  is  emptied.  E(|ual  parts  of  pure  sulphuric  or  hydrochloric  acid 
and  water  will  disinfect  a  stool  in  two  hours.  The  acid  corrosive  sublimate 
solution,  1  :  500,  will  do  it  in  six  hours,  and  a  5  per  cent,  solution  of  carbolic 
acid  (about  8  ounces  to  the  gallon)  will  do  it  in  twenty-four  hours.  If  solid 
faeces  be  present,  they  must  be  broken  up  and  thoroughly  mixed  with  the  solu- 
tion. Strong  milk  of  lime,  made  by  slacking  fresh-burned  quicklime  and  stir- 
ring up  the  fresh  powder  in  twice  its  bulk  of  water,  will  kill  typhoid  bacilli  in 
equal  parts  of  a  fresh  liquid  stool  in  about  half  an  hour.  If  the  problem  is  to 
deal  with  large  masses  of  excreta,  as  in  an  old  privy-vault,  the  chloride  of  lime 
or  5  per  cent,  carbolic-acid  solutions  are  the  best.  Sulphate  of  iron  is  a  deodor- 
ant for  masses  of  excreta  or  sewage,  but  it  is  not  a  disinfectant,  and  is  but 
slightly  antiseptic.     Its  use  is  not  to  be  recommended. 

A  5  per  cent,  solution  of  sulphate  of  copper,  a  10  per  cent,  solution  of  chlo- 
ride of  zinc,  and  a  15  per  cent,  solution  of  chlorinated  soda  will  kill  the  ordi- 
nary bacteria,  but  not  spores.  Such  solutions  are  more  costly  than  the  substances 
previously  mentioned  and  present  no  special  advantages.  Most  of  the  patent 
and  proprietary  disinfectants  on  the  market  are  useless,  and  those  that  are  not 
cost  from  ten  to  one  hundred  times  as  much  as  the  satisfactory  solutions  above 
given.  The  physician  has  no  guarantee  that  their  composition  remains  constant, 
and  had  better  confine  his  prescriptions  to  fresh-made  articles  of  known  com- 
position and  efficiency.  For  certain  special  and  limited  purposes,  as  in  dealing 
with  the  micrococci  of  suppuration  and  occasionally  to  sterilize  the  hands  of  the 
obstetrician  or  surgeon,  the  solution  of  peroxide  of  hydrogen  is  convenient  and 
useful.  The  hands  of  the  surgeon  and  his  assistants,  as  well  as  the  skin  of  the 
patient,  may  be  disinfected  by  washing  first  in  a  warm  saturated  aqueous  solu- 
tion of  permanganate  of  potash,  then  in  warm  saturated  aqueous  solution  of 


ISOLA  TJOX. — FOOD.  21 

oxalic  acid,  and  finally  in  corrosive  sublimate,  1  :  500.  The  body  of  a  person 
dying  of  infectious  disease  should  be  \vrapi>e(l  in  a  slieet  thoroughly  saturated 
with  the  strong  corrosive-sublimate  or  chloride-of-lime  solution. 

Isolation. 

That  it  is  desirable  to  prevent  communication  between  healthv  persons  and 
persons  suffering  from  communicable  disease  is  generally  admitted  ;  but  how 
this  is  to  be  done  without  causing  additional  suffering  and  danger  to  the  sick, 
or  great  inconvenience  and  cost  to  others,  is  sometimes  a  diftirult  question.  Bv 
the  laws  of  Moses  the  leper  was  to  be  driven  out  of  tiie  communitv  and  liis 
house,  clothing,  etc.  destroyed  by  fire,  but  at  present  it  is  required  that  the 
leper  shall  be  cared  for  as  well  as  the  community.  As  regards  individual 
cases,  when  the  family  occupies  a  separate  house,  one  room  of  which  can  be 
given  up  to  the  sick  person  and  his  attendant,  it  is  always  theoretically  pos- 
sible to  provide  such  isolation  as,  combined  with  projier  disinfection,  is  suffici- 
ent to  secure  protection  for  the  rest  of  the  family  and  of  the  community ;  but 
it  is  difficult,  especially  in  mild  cases  of  scarlatina,  diphtheria,  measles,  etc.,  to 
make  sure  that  such  isolation  and  disinfection  are  properly  carried  out,  and  in 
tenement-houses  and  where  the  family  occupies  but  one  room  it  is  practically 
impossible  to  do  this,  and  therefore  it  is  highly  desirable  that  special  hospitals 
be  provided  for  the  care  of  such  cases. 

One  of  the  most  important  questions  which  the  physician  is  called  on  to 
answer  in  scattered  or  so-called  sporadic  cases  of  the  acute  contagious  diseases 
of  children  is  as  to  the  time  during  which  the  child  should  lie  kept  isolated. 
This  varies  for  each  specific  disease,  and  varies  somewhat  in  individual  cases, 
but  the  following  may  be  considered  as  the  minimum  time,  after  the  apjiearance 
of  the  eruption  or  other  specific  symptom,  which  should  elapse  before  the  child 
is  permitted  to  be  with  other  children  :  Scarhitina,  40  days  ;  measles,  25  days  ; 
whooping  cough,  40  days;  mumps,  28  days;  rcHlicln,  14  days.  As  regards 
dij)htheria,  the  time  is  usually  given  as  40  days,  but  the  fact  is  that  it  should 
date  from  the  com])lete  destruction  of  the  specific  bacilli,  as  shown  by  bac- 
teriological examination,  and  the  time  required  to  demonstrate  that  such 
destruction  has  l)cen  effected  mav  varv  from  ten  davs  to  eiy-ht  weeks. 

The  isolation  of  a  mniibcr  of  people — as,  for  instance,  the  crew  and  pas- 
sengers of  a  vessel  in  what  is  known  as  maritime  quarantine,  or  of  a  town  in 
which  an  epidemic  is  raging — is  occasionally  useful  for  a  short  time  to  allow 
disinfection,  vaccination,  etc.  to  be  carried  out. 

Food. 
The  force  expended  in  a  licallhy  man  doing  an  average  day's  work  is 
equal  to  about  8400  fi)ot  tons,  of  which  2H40  l"<'<it  tons  an-  used  in  the  pro- 
duction of  heat.  This  force  must  l)e  supplied  by  (he  tissues  and  fluids  of  the 
bodv,  which,  in  turn,  must  obtain  it  fi-oiii  food.  It  is  stored  in  the  fo(»(l  in 
complex  compounds  of  carbon,  hydrogen,  oxygen,  and  nitrogen,  which  can 
easily  be  reduced  to  siinjdcr  combinations,  and  in  such   re<luction   give  out  the 


22  HYGIENE. 

force,  derived  mainly  from  the  sun's  heat,  which  has  been  stored  up  by  green 
plants. 

The  diseases  connected  with  food  may  be  due  to  defective  or  excessive  sup- 
ply, especially  of  certain  principles,  or  to  harmful  or  poisonous  substances  or 
living  organisms  contained  in  it,  and  include  such  various  forms  as  rickets, 
scurvy,  gout,  alcoholism,  and  specific  and  parasitic  diseases  of  various  kinds. 
Certain  substances,  such  as  phosphorus,  lime,  iron,  and  potash  salts,  are 
required  to  maintain  a  healthy  condition  of  the  body — not  to  furnish  force, 
but  to  supply  structural  material.  Phosphate  of  lime  constitutes  about  50 
per  cent,  of  bone,  and  if  the  supply  is  deficient  bone-softening,  or  rickets,  may 
be  produced.  Iron  is  an  essential  constituent  of  red  blood-corpuscles ;  if  the 
supply  is  deficient,  anaraia  is  the  result.  If  the  potash  salts  are  deficient, 
scurvy  is  produced,  especially  if,  at  the  same  time,  chloride  of  sodium  is  taken 
in  excess.  A  continued  diet  of  starchy  foods  and  salt  meats  without  fresh 
vegetables,  fruits,  or  potatoes  will  usually  produce  scurvy. 

The  amount  of  food  required  daily  by  a  laboring  man  doing  moderate  work 
should  include  about  125  grams  of  proteids,  the  same  of  fats,  and  450  grams 
of  carbohydrates  or  the  starchy  foods  ;  and  he  will  get  this  in  about  20  ounces 
of  meat,  22  ounces  of  bread,  10  ounces  of  potatoes,  and  3  or  4  cups  of  coffee. 
The  cookino;  of  food  is  desirable  to  make  it  tender  and  soluble  in  the  digestive 
fluids,  to  give  it  an  agreeable  flavor,  and  to  kill  parasites.  The  most  danger- 
ous animal  parasite  in  meat  is  the  trichina  spiralis.  It  is  killed  by  thorough 
cooking,  and  it  is  not  worth  while  to  take  any  special  precautions  against  it 
merely  in  order  that  a  few  men  may  eat  their  pork  raw  with  impunity.  The 
flesh  of  animals  dying  of  acute  disease  is  not  dangerous  if  well  cooked,  but  it  is 
not  a  desirable  article  of  food.  The  flesh  of  tuberculous  animals  is  somewhat 
dangerous  even  when  cooked.  Probably  f  of  1  per  cent,  of  the  beef  sold  in 
market  comes  from  animals  in  whom  tubercle  existed  at  the  time  of  death. 
The  systematic  inspection  of  all  animals  which  are  to  be  slaughtered  for  food 
before  they  are  killed,  and  of  the  meat  after  killing,  is  desirable.  This  can 
best  be  done  in  public  abattoirs.  As  a  general  rule,  animals  affected  with 
anthrax,  septicaemia,  glanders,  cattle  plague,  swine  plague,  sheep-pox,  and 
rabies  should  be  killed  and  the  bodies  destroyed. 

In  cases  of  foot-and-mouth-disease,  acute  pneumonia,  actinomycosis, 
dropsy,  tuberculosis,  and  non-specific  febrile  disease  the  meat  should  be  care- 
fully examined  after  slaughtering  to  determine  whether  any  part  of  it  is  fit 
for  food  or  for  industrial  purposes. 

The  meat  of  animals  dying  of  disease,  and  of  very  young  animals,  should 
not  be  used  for  food 

Of  all  articles  of  food,  milk  is  one  of  the  most  important  from  the  sanitary 
})oint  of  view.  It  is  used  uncooked  more  than  most  other  articles  of  food  ;  it 
is  often  adulterated  ;  it  contains  numerous  bacteria,  for  which  it  forms  an 
excellent  culture  fluid,  and  a  number  of  typhoid  fever,  scarlet  fever,  and 
diphtheria  epidemics  have  been  traced  to  the  use  of  milk  from  a  particular 
dairv.     It  mav  also  contain  the  bacillus  of  tubercle,  and  a  certain  amount  of 


EXERCISE.  23 

the  tuberculous  meningitis  and  tabes  niesenterioa  of  infants  is  no  doubt  causal 
in  this  way.  It  may  be  sterilized  by  heating  it,  but  tlie  heat  required  to  pro- 
duce complete  sterilization  injures  it  as  a  food  for  infants,  and  raising  it  to  a 
temperature  of  160°  appears  to  be  sufficient  to  prevent  the  progress  of  tlie 
lactic-acid  fermentation  for  as  long  as  it  is  usually  required  to  keep  it.  In 
case  of  a  localized  outbreak  of  typhoid  fever  the  milk-supply  should  i)r 
investigated. 

With  the  exception  of  milk,  the  adulterations  of  food  practised  in  this 
country  are  of  little  sanitary  importance.  Ground  spices,  coifee,  etc.  are  gen- 
erally adulterated  more  or  less,  but  not  dangerously  so.  Tiie  most  dangerous 
adulterations  are  those  of  drugs  and  of  coloring  matters. 

Oleomargarine,  if  properly  made,  is  not  dangerous  and  is  a  useful  article 
of  food. 

The  production  of  a  form  of  chronic  arsenical  poisoning  by  emanations  or 
dusts  given  off  from  colored  wall-papers  containing  arsenical  pigments  occa- 
sionally, though  very  rarely,  occurs.  It  probably  requires  a  marked  pecu- 
liarity in  constitution,  as  well  as  the  ingestion  or  inhalation  of  the  very  small 
quantities  of  arsenic  which    are   given  off  from   such  a  source,  to  produce 

disease. 

Exercise. 

The  usual  estimate  of  the  amount  of  muscular  exercise  required  to  keep  a 
man  in  good  condition  is  that  it  should  equal  about  150  foot-tons,  or  a  walk 
on  level  ground  of  about  nine  miles.  Each  individual  has  his  own  pecidiari- 
ties  in  this  respect,  and  requires  a  particular  amount  to  secure  good  appetite, 
complete  digestion,  restfid  sleep,  and  freedom  from  too  great  accumulation 
of  fat.  It  depends  on  the  amount  and  kind  of  food  taken  as  much  as  upon 
anything  else  under  ordinary  circum.stances.  In  addition  to  its  general  effects 
on  health,  it  may  be  employed  to  strengthen  particular  groups  of  muscles  for 
the  purpo.se  of  correcting  faulty  development  or  to  ])ri)duce  prompt  co-ordina- 
tion, or,  as  it  is  commonly  called,  "skill,"  in  the  performance  of  certain  actions. 
It  may  also  be  used  mainly  for  its.  effects  on  the  nervous  centres,  which  aiv 
quite  as  important  as  those  on  the  mu.scles.  The  exercis<'  used  in  training  [\n- 
a  boat-  or  foot-race  is  designed  not  only,  or  even  maiidy,  to  increase  the  size 
and  strength  of  the  muscles  of  the  arms,  legs,  and  trunk,  l)ut  to  produce  a 
heart,  large  blood-vessels,  and  hnigs  Avhich  will  be  competent  to  receive,  propel, 
and  aerate  the  greatly-increased  quantity  of  blood  which  is  forced  to  them  in 
the  violent  effort  of  a  "  .spiwt."  Owing  to  the  valves  in  the  veins,  the  con- 
traction of  the  muscles  of  the  extremities  forces  the  blood  in  the  veins  inward 
to  the  heart,  and  when  these  contractions  are  rapid,  (continued,  and  strong,  ihcy 
exert  a  powerful  pumping  action  on  the  blood,  :ui(l  at  the  same  lime  inuch  in- 
crease the  normal  quantity  of  carbonic  acid  rontaiiicd  in  it.  In  tiic  course  of 
six  weeks'  training,  with  plenty  of  running,  dumb-bell  work,  etc,  a  man  ^i^vi^ 
a  new  heart,  a  bigger  and  stronger  one,  with  larger  oriliees  and  i.iiliiionaiy 
arteries  and  veins,  provided  always  that  his  training  is  not  overdon.-.  II"  now, 
after  the  race  is  over,  he  ceases  to  take  exerci.se,  this  large  heart   and  arteries 


24  HYGIENE. 

must  readjust  themselves  to  the  changed  conditions,  and  there  is  some  risk  in 
the  degenerations  by  which  this  change  is  accomplished.  It  is  not  wise  to  create 
in  the  system  an  artificial  and  excessive  demand  for  exercise  to  secure  comfort 
and  pleasure,  when  such  demand  is  not  likely  to  be  gratified  in  future  years. 
The  takinsf  of  exercise  merely  for  its  own  sake  soon  becomes  to  most  men  a 
task  for  which  they  grudge  the  time,  and  to  get  rid  of  which  they  are  glad  to 
find  an  excuse.  It  is  for  this  reason  that  companionship  in  exercise  is  desirable, 
or  that  it  should  be  obtained  in  making  exertion  for  some  other  object.  For 
young  men  and  boys  gymnastic  exercises  are  by  no  means  a  complete  and  sat- 
isfactory substitute  for  the  ordinary  out-of-door  games  and  athletic  contests, 
partly  because  they  are  not  entered  into  with  such  zest  and  enjoyment,  and 
})artly  because  they  do  not  exercise  the  brain  so  much.  Work  in  the  gymna- 
sium should,  however,  be  used  as  an  accessory  to  games,  and  under  competent 
direction  and  supervision  it  will  effect  much  in  developing  special  groups  of 
muscles  which  are  in  need  of  increase  of  size  and  power,  and  it  is  also  well 
suited  to  the  needs  of  men  of  middle  age. 

Mere  muscular  strength  and  development  furnish  little  protection  against 
specific  epidemic  diseases. 

Clothing  and  Bedding. 
From  the  hygienic  point  of  view  the  value  and  defects  of  particular  kinds 
and  styles  of  clothing  are  judged  by  the  completeness  with  which  they  protect 
the  person  from  the  eifects  of  extremes  of  temperature,  the  extent  to  which 
they  interfere  with  the  circulation  or  the  shape  or  movements  of  the  body  or 
limbs,  and  the  freedom  with  which  they  permit  the  exhalations  from  the  skin 
to  pass  oif  into  the  surrounding  atmosphere.  The  diseases  due  to  insufficient 
clothing  of  the  upper  part  of  the  body  or  of  the  limbs  occur  chiefly  in  young 
children  and  in  women.  Undue  compression  of  certain  parts  of  the  body  by 
tight  lacing,  close-fitting  sleeves,  garters,  shoes,  etc.  occurs  chiefly  in  women  who 
try  to  follow  the  fashions  of  the  day.  As  a  rule,  linen  garments  next  the  skin, 
or  linen  sheets,  are  not  desirable,  and  by  persons  of  rheumatic  or  neuralgic  tend- 
encies they  should  be  carefully  avoided.  In  cool  weather,  or  when  rapid  changes 
in  temperature  are  likely  to  occur,  woollen  under-clothing  is  best.  It  conducts 
heat  badly  and  absorbs  perspiration  readily.  During  exercise  in  warm  weather 
a  man  with  woollen  under-clothing  will  at  first  feel  warmer  than  the  man  who 
has  cotton  or  linen  next  his  skin,  but  after  a  little  time  the  difference  in  this 
respect  will  be  small  ;  and  when  the  exertion  ceases  the  man  with  the  woollen 
under-clothing  will  be  much  less  apt  to  catch  cold  or  to  have  twinges  of  mus- 
cular rheumatism.  The  chief  objection  to  woollen  under-clothing  in  warm 
weather  is  that  men  are  not  likely  to  change  it  as  often  as  is  desirable.  Pure 
wool  under-clothing  requires  more  skill  in  washing  to  prevent  shrinkage  and  the 
loss  of  some  of  its  desirable  properties  than  is  usually  obtainable.  Some  per- 
sons, usually  women,  assert  that  they  cannot  wear  woollen  next  the  skin  because 
of  the  irritation  which  it  produces,  but  if  fine  woollen  or  merino  garments  be 
used,  this  objection  almost  always  disappears  in  about  two  weeks.    In  very  cold, 


OCCUPA  TIOX,  25 

windy  weather  skins,  furs,  and  leather  give  the  greatest  proteetion.  It  is  not 
healthy  to  wear  waterproof  elothing  continuously  for  any  great  length  of  time. 
In  hot  weather,  in  the  shade,  thin  e(»tton  or  linen  elothing  is  the  most  comfort- 
able. In  the  sun,  color  is  of  more  importance  than  texture  or  material  as  a  pro- 
tection against  heat,  white  being  the  coolest ;  in  the  shade,  color  makes  very  little 
difference  in  this  respect.  Dark-colore<l  clothing  absorbs  and  retains  odors  more 
readily  and  persistently  than  light-colored  clothing  of  the  same  material  and 
texture,  and  wool  more  than  cotton  or  linen.  The  most  comfortable  and  healthy 
bed  is  composed  of  a  hair  mattress  on  metid  s]>rings,  with  cotton  sheets  and 
woollen  blankets.  Feather  beds  are  not  desirable.  It  is  best  that  each  person 
should  have  a  separate  bed.  Clothing  may  be  the  means  of  transmission  of 
infection,  either  from  the  homes  of  those  who  manufacture  it  or  from  those  who 
have  worn  it,  as  by  so-called  second-hand  clothing.  The  virus  of  small-pox, 
of  scarlatina,  and  of  yellow  fever  has  been  transmitted  through  clothing  and 
beddino;,  and  the  disinfection  of  such  articles  in  cases  of  contagious  disease  is 
of  much  practical  importance. 

Occupation. 
Almost  every  occupation  produces  special  liability  to  certain  forms,  and  a 
certain  amount  of  immunity  from  other  forms,  of  disease  or  injury  on  the  part 
of  those  engaged  in  it,  but  the  net  result  of  a  particular  trade  or  profession 
on  the  health  and  life  of  men  is  often  very  difficult  to  determine.  Only  men 
of  considerable  strength  and  vigor  can  luidergo  the  muscular  exertion  required 
in  certain  forms  of  labor,  hence  weak  and  sickly  men  either  do  not  engage  in 
these  occupations  or  leave  them  for  lighter  work.  AVhat  are  called  easy,  light 
occupations  attract  weak  lives  ;  hence  the  difference  in  the  death-rate  of  black- 
smiths and  of  clerks  cannot  be  taken  as  the  measure  of  the  difference  in  hcallh- 
fulness  of  the  two  occupations.  The  average  age  of  those  engaged  in  a  jiar- 
ticular  occupation  is  also  of  great  influence  on  the  death-rate,  which  for  this 
reason  tends  to  be  lower  for  medical  students  than  for  practising  physicians. 
The  influence  of  i)lace  of  residence  and  of  social  status  and  habits,  especially 
as  to  use  of  alcohol,  is  also  very  great  in  certain  kinds  of  occui)ations.  The 
most  extensive  and  reliable  series  of  data  as  to  the  relative  death-rates  in  dif- 
ferent occupations  yet  i)ubllshed  is  given  by  Dr.  Ogle  in  the  supplement  to  the 
forty-fifth  annual  report  of  the  Registrar-General  of  England,  and  in  a  |)ap(>r 
read  before  the  Hygienic  Congress  in  London  in  18ill.  The  following  (A)  is 
his  table  of  com])arative  mortalities  of  men  between  twenty-five  anil  sixty-five 
years  of  ag(!  in  different  occupations,  the  death-rate  <»f  clergymen,  the  lowest 
of  all,  being  taken  as  the  standard  of  comparison  and  represented  by  100. 
The  si)ecial  causes  of  disease  and  injury  dindly  coiuiecled  with  particular 
occu))ations  may  be  classed  as  follows:  viz.  1,  accidents;  2,  poisonous 
materials;  3,  dust;  4,  gases  and  vapors;  5,  excessive  temperature  ;  (i.  abnor- 
mal atmospheric  ])ressure  ;  7,  excessive  use  or  strain  of  nrlain  parts  of  the 
body  ;  8,  special  exposure  to  contagious  or  i)arasitic  diseases.  Of  I  lie  poison- 
ous'materials,  lead  is  the  most  important,  as  pro.hicing  the  greatest  amount  of 


26 


HYGIENE. 


A. — Coinparative  Mortality  of  Men  {twenty-jive  to  sixty-five  years  of  age)  in 

Different  Occupations,  1881-8S. 


Occupation. 


Clergymen,  priests,  ministers  . 

Lawyers 

Medical  men 

Gardeners 

Farmers 

Agricultural  laborers  .... 

Fishermen 

Commercial  clerks 

Commercial  travellers      .    .    . 
Inn-keepers,  liquor-dealers 

Inn,  hotel  service 

Brewers 

Butchers 

Bakers 

Corn-millers 

Grocers 

Drapers 

Shopkeepers  generally     .    .    . 

Tailors 

kShoemakers 

Hatters 

Bookbinders 


Compar. 
Mortal. 


100 
152 
202 
108 
114 
126 
143 
179 
171 
274 
397 
245 
211 
172 
172 
139 
159 
158 
189 
166 
192 
210 


Occupation. 


Carpenters,  joiners 

Cabinet-makers,  upholsterers    .    .    . 
Plumbers,  painters,  glaziers  .... 

Blacksmiths 

Engine,  machine,  boiler-makers  .    . 
Silk  manufacture     ....... 

Wool,  worsted  manufacture  .... 

Cotton  manufacture 

Cutlers,  scissor-makers 

Gunsmiths 

File-makers 

Paper-makers 

Glass-workers 

Earthenware-makei's 

Coal-miners 

Cornish  miners 

Stone,  slate-quarriers 

Cab,  omnibus  service 

Railway,  road,  clay,  etc.  laborers  .    . 
Costermongers,  hawkers,  street-sellers 

Printers 

Builders,  masons,  bricklayers    .    .    . 


Compar. 
Mortal. 


148 
173 
216 
175 
155 
152 
186 
196 
229 
186 
300 
129 
214 
314 
160 
331 
202 
267 
185 
338 
193 
174 


disease.  Manufacturers  of  white  lead,  painters  and  glaziers,  plumbers,  work- 
ers in  rubber  factories,  and  file-makers  are  specially  liable  to  be  affected  from 
this  cause  with  colic,  local  paralysis,  and  various  obscure  forms  of  disease  of 
tiie  nervous  system  and  of  the  urinary  organs.  Tailors  and  seamstresses 
sometimes  suffer  from  lead-poisoning  from  the  use  of  sewing  silk  treated 
with  sugar  of  lead,  especially  if  they  have  the  habit  of  biting  off  such  thread. 
Chronic  mercurial  poisoning  occurs  in  gilders,  looking-glass  makers,  and  hat- 
ters ;  necrosis  of.  the  jaws  in  Nvorkers  in  phosphorus,  especially  in  match- 
makers ;  arsenical  poisoning  in  zinc-  and  brass-founders  and  in  workers  in 
papers,  feathers,  etc.  tinted  with  arsenical  colors.  Irritating  dusts  produce 
diseases  of  the  lungs  and  air-passages  which  predispose  to  phthisis,  as  will  be 
seen  by  the  following  table  (B)  of  Dr.  Ogle : 

B. — Comparative   Mortality  of  Males  in    certain   Dust-inhaling    OccujMtions 
from  Phthisis  and  Diseases  of  the  Respiratory  Organs. 


Occupation. 


Coal-miners 

Carpenters,  joiners 

Bakers  .        

Masons,  bricklayers,  builders 
Wool,-  worsted-workers      .    . 

C'otton-workers 

Quarrymen 

Cutlers 

File-makers 

Earthenware-makers  .    .    .    . 

Cornish  miners 

Fishermen 


Comparative  Mortality  from- 


Diseases  of 

Phthisis  and  Dis- 

Phthisis. 

Respiratory 

eases  of  Respir- 

Organs. 

atory  Organs. 

64 

102 

166 

103 

67 

170 

107 

94 

201 

127 

102 

229 

1.30 

204 

234 

137 

137 

274 

156 

138 

294 

187 

197 

384 

219 

177 

396 

239 

326 

565 

349 

231 

580 

55 

45 

100 

HABITATIONS. 


27 


Alcoliol  is  also  to  be  reckoned  among  the  poisonous  materials,  as  is  shown 
by  the  following  table  : 

Mortality  of  Dealers   in   Liquor  {twenty-jive  to  sixty-jive  years  of  ar^e)  from 
Various  Di^^eases,  compared  ivith  that  of  Men  generally  of  the  same  Ages. 


Diseases. 


Alcoholism 

Liver  disease 

(iout 

Diseases  of  nervous  system    . 

Suicide 

Diseases  of  urinary  system    . 
Diseases  of  circulating  system 
Other  diseases 


All  causes 


Mortality  of— 

Liquor- 

Mi-n 

dealers. 

gfiiurally. 

55     . 

10 

240 

39 

13 

3 

200 

119 

26 

14 

83 

41 

140 

I'JO 

764 

653 

1521 


1000 


Dangerous  gases  and  vapors  are  evolved  in  chemical  and  color  works,  in  the 
manufacture  of  sulphate  of  ammonia  from  the  refuse  of  gas-works,  in  India- 
rubber  works,  etc.  Excessive  temperature  and  rapid  changes  of  temperature 
affect  glass-blowers,  puddlers,  and  firemen  in  steamships  and  workers  in  certain 
mines,  producing  diseases  of  the  respiratory  organs  and  rheuniatic  affections. 
Abnormities  of  atmospheric  pressure,  and  especially  rapid  changes  in  the  pres- 
sure, affect  workmen  in  compressed  air,  producing  rupture  of  the  membraiui 
tvmpani  and  paralytic  aflFections  of  the  nervous  system  known  collectively  as 
the  "  caisson  disease."  The  chief  danger  occurs  in  the  rapid  passage  from  a 
denser  to  a  thinner  air,  producing  tendencies  to  congestion  and  hemorrhages  in 
internal  organs.  For  the  same  reason  persons  having  tuberculous  cavities  in 
the  lungs  are  liable  to  attacks  of  pnlmonary  hemorrhage  in  passing  rapidly  by 
rail  to  high  altitudes.  For  most  of  the  special  causes  of  disease  in  factories  and 
workshops  the  specially  important  precautions  are  personal  cleanliness  and 
abundant  ventilation.  In  many  cases  dust  or  vapors  can  be  at  once  removed 
by  fans  or  blowers,  and  in  most  cases  dangerous  and  offensive  gases  connected 
with  waste  products  can  be  avoided  or  converted  into  materials  of  value  by 
projjcr  methods  of  dealing  with  these  products. 

Habitations. 
Physicians  are  rarely  consulted  in  the  selection  of  a  site  for  a  dwelling,  and 
oven  more  rarely  in  the  ])rej>aration  of  plans.  Occasionally,  however,  they  are 
called  upon  for  an  opinion  as  to  whether  a  particular  house  is  unhealthy,  and, 
if  so,  what  should  l)e  done  to  improve  if,  or  whether  a  cliangc  of  residence  is 
necessary  to  secure  satisfactory  resnlts  in  the  treatment  of  a  |)arlictilar  ease. 
In  cities  most  men  select  their  dwelling-i)laces  with  special  reference  to  cost, 
vicinity  to  their  plaee  of  business,  kind  <»('  neighbors,  etc.,  rather  than  to  sani- 
tary conditi(jns,  with  regard  to  wliicii  (li(y  have  little  choice.  The  sanitary 
character  of  a  building-site  is  determined  maiidy  by  its  clcvalion  aiid  exposure 
to  i)revailing  winds  and  the  dryness  and  kind  of  soil  in  the  iinincdiate  vicinity. 


28  HYGIENE. 

An  elevated  site  is  desirable  as  securing  abundance  of  fresh  a-ir  and  facilities 
for  good  drainage;  but  in  the  rural  districts  convenience  of  access  and  of 
water-supply  must  often  be  the  first  points  to  be  considered.  In  some  locali- 
ties shelter  from  cold  northerly  winds,  and  in  others  from  winds  coming  from 
over  low  marshy  grounds,  is  very  important.  Rock,  gravel,  and  pure  sands 
are  healthier  sites  than  clay  and  alluvial  soils,  because  they  are  dryer  if  suffi- 
cieutlv  elevated.  Damp  sites  are  unhealthy,  having  a  special  tendency  to  pro- 
duce or  to  aggravate  diseases  of  the  air-passages  and  rheumatic  alFections. 
The  inhabitants  of  such  sites  are  especially  liable  to  pulmonary  phthisis  and 
to  diphtheria,  possibly  because  the  specific  bacilli  and  spores  of  these  affections 
retain  their  vitality  better  in  such  localities,  possibly  because  the  slight  colds 
and  catarrhs  which  such  sites  tend  to  produce  modify  the  respiratory  tract  so 
as  to  make  it  easier  for  the  specific  germs  to  effect  a  lodgment  and  to  multiply 
and  develop.  Under  the  same  general  conditions  of  climate  diseases  of  the 
respiratory  organs  are  more  fatal  on  damp  soils  than  on  dry  ones. 

Soil  moisture  or  dampness  refers  to  the  water  in  soils  that  also  contain  air. 
When  there  is  no  air  in  the  soil  interstices  and  the  water  is  continuous,  it  is 
called  ground  water.  All  soil  contains  a  large  proportion  of  interstices  filled 
with  either  air  or  water :  in  coarse  dry  sand  or  gravel  or  in  coarse  sandstone 
this  amounts  to  one-third  of  the  bulk.  When  filled  with  air  this  air  is  always 
iii  motion,  and  enters  buildings  freely  through  the  floors  and  sides  of  the  cel- 
lars or  basements,  especially  in  cold  weather,  when  the  air  in  the  house  is 
warmer  than  that  outside.  Soil  air  always  contains  a  greater  proportion  of 
carbonic  acid  than  the  atmosphere,  and  this  proportion  increases  with  the 
depth.  Tiius,  while  the  atmosphere  contains  about  0.4  parts  per  1000  of  COg, 
the  upper  layers  of  the  soil  contain  from  1  to  3  parts,  and  at  a  depth  of  fifteen 
feet  it  may  contain  from  50  to  70  parts. 

In  cities  the  soil  of  streets  is  liable  to  contain  illuminating  gas  from  leaky 
mains,  and  this  may  be  drawn  into  the  cellar  of  a  house  from  a  distance  of 
from  thirty  to  fifty  feet.  The  excess  of  carbonic  acid  in  soil  air  is  greater  in 
soils  containing  much  organic  matter,  and  is  therefore,  to  a  certain  extent,  a 
measure  of  the  organic  contamination  of  the  soil ;  but  it  does  not  always 
depend  on  local  oxidation  processes,  nor  is  it  in  itself  a  matter  of  much  sani- 
tary iraj)ortance.  It  is,  however,  necessary  to  bear  in  mind  this  excess  of  COj 
in  cellars,  due  to  soil  air,  in  testing  the  air  of  rooms  with  reference  to  ventila- 
tion, for  otherwise  very  erroneous  conclusions  may  be  drawn. 

Like  the  soil  air,  the  soil  or  ground  water  is  continually  in  motion.  It 
varies  in  height  at  different  places  and  at  the  same  place  at  different  times. 
Where  the  ground  water  is  always  below  fifteen  feet  from  the  surface,  it  is 
healthy  so  far  as  this  is  concerned.  When  the  level  of  the  ground  water  is 
above  this,  it  is  healthier  when  it  remains  at  about  the  same  level  than  when 
it  fluctuates.  In  some  places,  as  in  Munich,  typhoid  fever  increases  as  the 
ground  water  falls,  but  this  is  by  no  means  always  the  case,  and  it  probably 
dei)ends  to  a  considerable  extent  on  the  condition  and  amount  of  use  of  shallow 
wells. 


M  'A  TER-SUPPL  Y.  29 

As  the  soil  water  is  constantly  in  motion,  and  for  each  locality  this  motion 
is  tolerably  nniform  in  direction  and  velocity,  it  follows  that  in  })rivy-well  and 
cesspool  villages  and  towns  it  may  be  much  more  contaminated  in  one  part  of 
the  town  than  in  another. 

Nearly  every  form  of  micro-organism  may  be  found  in  the  soil  at  different 
places  and  times,  and  their  number  and  character  de])cnd  on  the  moisture  and 
temperature  and  on  the  presence  of  suitable  food  material.  From  the  sanitary 
point  of  view  the  most  important  of  these  are  the  Plasmodium  malarife,  the 
bacillus  of  typhoid,  of  tetanus,  of  anthrax,  of  tuberculosis,  of  diphtheria,  and  of 
cholera,  and  the  nitrifying  organisms.  The  pathogenic  micro-organisms  or  their 
j^roducts  may  pass  into  the  soil  water,  being  washed  down  by  rainfall,  or  into 
the  air  with  particles  of  the  surface  soil  blown  about  as  dust.  They  cannot  be 
drawn  far  through  soil  by  air-currents,  especially  if  the  soil  is  slightly  moist. 
To  prevent  ground  air  and  dam])ness  from  entering  the  cellars  of  dwelling- 
houses,  the  floor,  and  the  sides  of  the  cellar  up  to  ground  level,  should  be  laid 
with  bricks  soaked  in  asphalt.  A  cement  floor  is  quite  pervious  to  air  when 
it  becomes  dry.  In  low  sites,  and  especially  in  malarious  regions  in  warm 
climates,  it  is  better  to  have  no  cellar  beneath  the  house,  which  should  be 
raised  on  piers,  posts,  or  arches.  The  natural  processes  for  the  purification  of 
soil  containing  nuich  organic  matter  of  animal  origin,  such  as  the  made  ground 
in  the  suburbs  of  cities  or  the  ground  in  the  vicinity  of  leaky  cesspools  or  of 
graves,  is  a  slow  one,  requiring  from  three  to  eight  or  more  years,  according 
to  the  porosity  of  the  soil  and  the  accessibility  of  fresh  air  to  the  interstices. 
Hence,  when  a  system  of  sewerage  is  introduced  in  a  city  which  has  previously 
been  storing  up  its  filth  in  cesspools,  it  requires  some  time  for  the  nitrifying 
organisms  to  complete  the  work  of  purifying  the  polluted  soil. 

Water- Supply. 

Water  is  sometimes  considercnl  as  a  food,  because  it  is  taken  into  the  body 
through  the  alimentary  canal,  but  it  supplies  no  force  for  the  production  of 
either  heat  or  motion.  It  is,  however,  the  universal  medium  in  and  through 
which  the  processes  of  life  occur  and  the  products  of  vital  action  are  removed 
and  excreted.  58  per  cent,  of  a  man's  body  is  composed  of  water ;  he  must 
liave  from  60  to  90  ounces  a  day  in  his  food  and  drink  to  maintain  his  weight 
and  strengtli,  and  he  needs  a  nuich  larger  quantity  externally  (o  \irv\\  his  skin 
and  his  morals  in  good  condition.  In  a  fairlv  clcanlv  household  the  avera;re 
necessary  consumption  of  water  per  head  ])er  day  is  from  10  to  15  gallons.  Vuv 
all  pur])Oses  the  water-supply  of  a  town  should  not  be  less  than  IS  gallons  per 
head  per  day  ;  if  it  is  used  freely  and  ntmc  is  wasted,  it  will  r((|iiirc  about  25 
gallons  per  head  per  day.  The  average  sn])ply  in  (lie  larger  American  cities 
is  mon;  than  three  times  (his,  the  greater  |i:n(  lieiiig  wa>(ed  (hroiigh  leaky 
fixtures. 

This  constant  use  of  water  by  (^very  living  being  makes  the  quality  of  (he 
water  used  of  great  importance,  as  it  is  very  liable  to  contain  matters  injuri- 
ous to  health.     The  most  important  of  these  are  the  micro-organisms  which 


30  HYdTEXE. 

cause  disease,  and  especially  those  which  produce  diarrha?al  and  dysenteric 
affections,  cholera,  typhoid  fever,  and,  sometimes,  malaria. 

Water  may  also  contain  poisonous  salts,  as  of  lead,  or  excessive  amounts  of 
magnesia  and  lime,  giving  rise  to  goitre  or  to  calculus.  No  water  in  ordinary 
use  is  chemically  pure :  rain-water,  snow,  and  hailstones  contain  organic  mat- 
ter and  living  micro-organisms.  A  good  drinking  water  should  have  a  bluish 
tint  when  in  a  layer  of  three  feet  thick;  it  should  be  limpid,  cool,  without  odor 
when  cold  or  when  heated,  and  it  is  most  palatable  when  it  has  a  very  faint 
taste  of  acid  and  of  salt.  A  good  water  should  not  contain  more  than  20  parts 
of  lime  per  100,000,  or  it  will  be  "  hard,"  so  that  it  will  not  easily  form  a 
lather  with  soap  and  is  not  well  suited  for  laundry  and  cleansing  purposes. 

There  is  no  simple,  easy  means  by  which  any  one  can  assure  himself  that  a 
water  contains  nothing  harmful,  but  in  bad  cases  the  sense  of  smell,  taste,  and 
sig-ht  will  assure  him  that  it  is  not  fit  to  drink.  Bv  chemical  analvsis  w^e  can 
discover  the  amount  and,  to  some  extent,  the  source  of  the  foreign  matters  pres- 
ent, and  can  usually  tell  whether  it  is  contaminated  with  sewage  or  not.  This 
last  is  indicated  by  the  presence  of  an  excess  of  chloride  of  sodium  and  by  the 
long-continued  production  of  free  and  albuminoid  ammonia  in  distillation  with 
an  alkaline  permanganate,  indicating  the  presence  of  urea.  Much  care  is  neces- 
sary in  obtaining  the  samples  to  be  examined.  Chemical  analysis  tells  nothing 
about  the  living  organisms  in  the  water.  vSomething  may  be  learned  about 
these  by  mixing  a  drop  of  the  water  with  a  little  melted  peptone  gelatin, 
spreading  the  mixture  in  a  tube  or  on  the  bottom  of  a  thin,  shallow  glass 
dish,  and  cultivating  the  mixture.  In  this  way  it  is  possible  to  determine 
approximately  the  number  of  bacteria  in  a  given  quantity  (as  a  cubic  centi- 
metre) of  the  water,  and  the  nature  of  some  of  these  bacteria  can  be  discovered 
by  subsequent  pure  culture  methods ;  but  it  is  rarely  possible,  by  either  chem- 
ical or  bacteriological  analysis,  or  by  both  combined,  to  make  sure  that  a  water 
is  free  from  disease-germs,  although  it  is  otiten  possible  to  be  positive  that  it 
is  polluted. 

If  it  is  suspected  that  a  Avell  or  spring  is  being  polluted  from  a  neighbor- 
ing leal^y  cesspool  or  privy- vault,  the  question  can  sometimes  be  settled  by 
throwing  a  large  quantity  of  crude  carbolic  acid  or  of  common  salt  into  the 
cesspool  or  vault.  If  there  is  communication,  the  peculiar  odor  and  smell  of 
the  acid  or  a  considerably  increased  proportion  of  the  salt  will  be  found  in  the 
well  water. 

The  most  reliable  sources  of  what  is  ordinarily  called  a  j)ure  water-sup])ly 
are  springs  and  deep  wells  in  the  open  country  and  streams  coming  from  uncul- 
tivated and  uninhabited  uplands.  Surface  water  from  cultivated  land  is  dubi- 
ous;  streams  or  ponds  into  which  sewage  is  discharged,  and  springs  and  shal- 
low wells  in  cities,  furnish  dangerous  waters.  The  danger  is  mainly  due  to 
the  possible  ])resence  of  disease-producing  bacteria  which  have  passed  from  the 
bodies  of  sick  j)eople  into  the  water  through  sewage  contamination  or  as  air- 
blown  dust,  but  it  may  also  be  due  to  an  excess  of  the  products  of  organisms 
which  in  small  quantity  are  harmless.  / 


u'ATijn-.srrrLV.  31 

In  a  gpneral  way,  it  may  be  saitl  tliat  a  well  drains  a  fnnnol-.shaped  area, 
the  radius  of  tlie  tc.p  of  which  is  equal  to  its  depth,  and  this  whetlier  its 
diameter  is  two  inches  or  three  feet.  The  shape  and  area  of  tlie  o;round  which 
it  drains  depend  on  the  nature  of  the  water-bearing  strata  or  the  velocity  of 
the  ground-water  current,  and  on  the  amount  that  is  drawn  from  it. 

A  general  water-supply  is  desirable,  because  it  usually  gives  a  purer  and 
more  wholesome  water  than  the  wells  or  eisterns  of  a  town,  because  it  saves 
much  labor,  ])romotes  cleanliness,  lessens  the  danger  from  fires,  ])ermits  of 
watering  the  streets,  and  increases  comfort  and  hapj)iness  in   niauv  ways. 

On  the  other  hand,  when  a  general  water-suj)p]y  does  become  dangerously 
contaminated,  its  effects  are  widespread,  and  it  necessitates  the  provision  of 
means  whereby  the  large  amount  of  water  brought  in  and  made  foul  bv  use 
can  be  taken  out  again  without  producing  nuisance  or  danger  to  the  town 
itself  or  to  its  neighbors.  A  general  water-sujiply  may  become  polluted  at  its 
source,  or  while  it  is  in  an  open  stream  or  pond,  or  while  stored  in  reservoirs, 
or  while  in  the  distribution-pipes.  The  pollution  which  occurs  in  reservoirs 
is  due  to  the  growth  and  decay  of  various  species  of  algje  or  of  fresh-water 
sponges,  pnxlucing  unpleasai*t  odors.  Uncovered  reservoirs  more  frequently 
become  affected  in  this  way  than  covered  ones,  light  being  necessary  for  the 
development  of  the  algaj  which  jjroduce  them.  While  in  the  distributing 
pipes  the  water  may  become  contaminated  by  sewage  if  the  pipes  are  leaky, 
and  especially  if  the  supj)Iy  is  intermittent.  Such  contamination  may  be  sus- 
pected when  a  sudden  outbreak  of  typhoid  fever  occurs,  confined  to  the  houses 
supplied  by  a  ])articular  water-main,  and  there  is  no  other  circumstance  com- 
mon to  these  houses,  such,  for  instance,  as  a  common  milk-supply. 

The  tyi^hoid  bacillus  has  been  known  to  pass  many  hundred  feet  beneath  a 
mountain  and  infect  a  spring  at  its  base,  and  to  preserve  its  vitality  for  several 
weeks  in  excreta  thrown  out  on  snow,  and  then,  through  the  melting  of  the 
snow,  pass  into  a  stream  and  produce  an  extensive  epidemic. 

When  a  running  stream  has  been  pc^lluted  by  sewage,  a  j)rucess  of  self- 
purification  occurs  by  sedimentation,  by  the  action  of  bacteria,  and  of  microzoa 
which  feed  upon  the  organic  matters.  The  rapidity  and  completeness  with 
which  this  natural  purifying  process  goes  on  depend  on  the  nnioimt  of  dilution 
of  the  sewage,  the  presence  or  absence  of  fine  ])articles  of  clay,  which  proiluce 
sedimentation,  and  especially  on  the  amount  of  oxygen  present  in  the  water, 
which  determines  the  character  of  the  bacteria  which  fioini-li  in  it.  If  there 
is  abundance  of  oxygen,  those  bacteria  which  rc(|uire  It  lor  growth  will  mul- 
tiply and  consume  the  organic  mattei-  to  the  exclusion  (»f  other  forms.  Such 
l>acteria  are  called  aerobic — that  is,  air-loving — bacteria,  and  among  these  are 
the  nitrifying  organisms,  which  will  be  referred  to  liereafter  in  speaking  of  the 
filtration  of  sciwage. 

When  it  is  necessarv  to  u.>(;  water  which  lia>  heeu  polluted  by  >e\vage,  it 
may  Ix;  rendered  harndess  by  bi»iling,  and  thus  sterilizing  it,  or  by  certain 
methods  of  filtration  and  aeration,  'i'lie  only  >iiiall  hoiixhold  filters  which 
can  be  relied  on  t(j  remove  bacteria  are  tho-e  made  of  uuglazed  pr»rcelain,  and 


32  HYGIENE. 

these  will  only  do  so  for  two  or  three  days,  at  the  end  of  which  time  they 
must  be  thoroughly  cleansed  and  sterilized.  On  the  large  scale  the  cheapest 
and  most  satisfactory  filters  are  constructed  of  sand,  but  their  action  must  be 
intermittent,  as  will  be  explained  in  speaking  of  sewage  filtration.  Spongy 
iron  also  makes  a  g-ood  filter,  and  a  combination  svstem  bv  which  iron  is 
showered  through  the  water  in  a  revolving  cylinder,  with  subsequent  aeration 
and  sand  filtration,  gives  good  results. 

The  freezing;  of  water  does  not  destrov  the  vitalitv  of  the  micro-organ- 
isms  contained  in  it.  It  kills  some  of  the  soft  microcopci  and  bacteria,  but 
only  a  portion,  and  has  little  or  no  effect  on  spores.  The  bacillus  in  ty- 
phoid will  preserve  its  vitality  and  powers  of  development  in  ice  for  sev- 
eral months  ;  hence,  ice  cut  from  a  sewage-contaminated  pond  may  be  very 
dangerous. 

The  jurisprudence  of  water-sup])lies  is  in  an  unsatisfactory  condition  in  the 
United  States.  The  common  law  of  the  subject  rests  on  contradictory  decis- 
ions of  different  courts,  and  where  there  is  not  clear  and  definite  statute  law 
upon  the  subject  it  is  very  uncertain  in  any  given  case  as  to  how  far  manu- 
facturing or  other  interests  of  more  or  less  public  importance  will  be  allowed  to 
override  the  health  interests  of  individuals  or  of  small  communities.  The  gen- 
eral principle  is,  that  a  person  living  on  the  banks  of  a  stream  has  the  right 
to  demand  that  the  water  of  this  stream  shall  continue  to  come  to  him  in  its 
natural  purity  and  volume,  but  that,  if  pollution  has  been  going  on  for  twenty 
years  without  complaint  or  attempt  at  interference,  what  is  called  a  prescriptive 
right  to  continue  such  pollution  is  established. 

The  fact  that  a  person  or  corporation  owning  property  on  the  banks  of  a 
stream  does  not  use  the  water  does  not  prevent  them  from  bringing  an  action 
to  protect  themselves  against  the  acquirement  by  others  of  a  prescriptive  right 
to  pollute  the  stream,  thereby  depriving  them  of  their  rights  in  future.  It  has 
also  been  decided  in  one  case  that  the  ])rinciple  applies  to  subsoil  water  while 
on  its  passage  to  springs  or  wells,  and  that  therefore  the  placing  a  cesspool  or 
drainage  from  gas-works  in  such  a  position  as  to  pollute  a  well  is  good  ground 
for  action  for  damages. 

When  it  is  possible  to  prove  to  the  satisfaction  of  a  court  that  actual  dis- 
ease and  death  have  been  caused  by  the  pollution  of  a  water-suppl}^  bv  sew- 
age, no  doubt  the  nuisance  can  be  stopped  and  damages  collected  in  many 
cases  ;  but  it  is  rarely  possible  to  prove  this.  In  some  cases  it  is  a  question 
whether  it  is  not  best  for  the  public  to  abandon  a  stream  to  ])ollution,  so  long 
as  it  does  not  injure  the  public  health.  It  is  generally  admitted  that  the  dis- 
charge of  excreta  into  a  stream  the  water  of  which  may  be  used  lower  down 
for  driidving  purposes  is  unlawful,  but,  practically,  it  is  not  possible  to  pre- 
vent a  small  amount  of  this  contamination  in  most  cases.  What  amount  of 
contamination  is  excessive  and  unnecessary  is  a  question  to  be  decided  sep- 
arately for  each  particular  case. 

So  far  as  statute  law  is  concerned,  the  best  form  is  probably  that  of  the 


SEWAGE-DISPOSAL.  33 

State  of  New  York,  wliicli  authorizes  the  State  Board  of  Ileahli  "  to  make 
rules  and  reguhitions  for  protectnig  from  contamination  any  and  all  public  sup- 
plies of  potable  waters  and  their  sources  within  the  State." 

Sewage-Disposal. 

AVater-supply,  and  its  pollution  and  purification,  are  closely  connected  with 
the  subject  of  sewage-disposal.  \\\  "sewage"  in  this  connection  is  meant 
water  made  foul  by  nse  in  habitations  and  manufactories  or  by  street-wash- 
ings. It  is  a  complex  liquid,  containing  a  large  amount  of  organic  inattcr  and 
innumerable  micro-organisms,  but  varying  much  in  composition  in  different 
places,  or  in  the  same  sewer  at  different  hours  of  the  day.  Chemically,  and  as 
regards  the  amount  of  organic  matter,  the  sewage  from  towns  where  it  is  not 
allowed  to  connect  water-closets  with  the  sewers  does  not  differ  greatlv  from 
that  from  water-closet  towns.  Ordinary  sewage  has  been  drunk  with  impu- 
nity ;  diluted  sewage,  as  found  in  the  shallow  wells  of  most  small  towns  and 
villages  is  constantly  imbibed  with  onlv  occasional  bad  results.  The  sewage 
from  a  single  house  rarely  contains  the  specific  bacteria  of  cholera,  typhoid,  or 
dysentery,  but  that  from  a  large  city  will  rarely  be  free  from  those  of  tyjihoid, 
and  never  from  those  capable  of  producing  intestinal  irritation. 

In  considering  the  question  of  the  disposal  of  the  sewage  of  a  particular 
locality  there  must  be  taken  into  account  the  probability  of  its  containing  spe- 
cific causes  of  disease,  and  the  communication  of  these  to  water-supplies ;  its 
liability  to  produce  offensive  odors ;  its  effects  on  fish  or  on  the  iitness  of  a 
stream  for  manufacturing  purposes  ;  and  its  value  as  a  fertilizer.  When  there 
is  no  general  water-supply  the  amount  of  sewage  jiroduced  is  comparatively 
small,  and  it  is  usually  disposed  of  on  the  premises  by  iiuans  of  a  cesspool 
or  privy-vault  or  by  being  thrown  on  the  surface  of  the  ground  or  into  the 
gutter.  To  remove  it  entirely  from  a  town  some  system  of  water-carriage 
is  necessary,  and  this  requires  a  general  water-sujiply ;  while,  as  mentioned 
above,  a  general  water-supply  requires  some  kind  of  system  of  sewers  to 
remove  the  fouled  water.  1000  adults  excrete  each  day  about  250  })ounds  of 
faeces  and  375  gallons  of  urine.  Practically,  the  amount  of  sewage  from  a 
community  maybe  taken  as  equal  to  the  amount  of  its  water-su|)ply.  In 
considering  the  merits  of  different  systems  of  residential  sewage-disposal  the 
chief  points  to  be  borne  in  mind  are  as  follows:  1.  Fresh  sewage  conlains  a 
large  amount  of  dead  organic  matter  in  complex  forms  of  coinl»ination.  '1. 
These  complex  forms  are  to  be  decomposed  and  rerond)inc(l  in(o  siinpler  forms, 
such  as  nitrates,  ammonia  salts,  etc.,  in  which  the  combined  nitrogen  is  in  a 
form  suital)le  to  nourish  plants.  3.  The  nafiiral  pr<Mv:-s  of  elleeling  lliis  i>  by 
the  action  of  bacteria.  -1.  Tlie  l);icteria  wlii.'li  gr<»\v  nnd  multiply  be>(  wlicii 
there  is  little  f)r  no  free  oxygen  j)resent — /.  r.  tlic  :iMierol)ie  bacteria — do  not 
effect  this  decom])osition  into  sim])!*-  salts,  but  pnuhice  substances  which  are 
more  complex,  more  dangerous  to  health,  and  more  ofVcnsiyc  to  the  sens<' of 
smell  tlian  are  the  ])ro(lucts  of  tliose  which  grow  be^t  in  nbundance  of  iVee 
oxygen — the  arobic  bacteria.  5.  In  mo<t  eases  it  is  not  desirable  to  prevent 
V..I,.  T.— 3 


34  HYGIENE. 

the  action  of  the  serobic  bacteria,  which  should  be  favored  as  much  as 
possible. 

In  cities,  towns,  and  villages  it  is  not  desirable  to  turn  the  sewage  into 
cesspools.  If  these  are  watertight,  which  is  rarely  the  case,  the  aerobic  bac- 
teria can  act  only  on  the  upper  surface;  offensive  gases  are  generated  below, 
and,  as  the  vaults  must  be  emptied  from  time  to  time,  the  cost  of  doing  so  is 
considerable,  especially  if  there  is  a  general  water-supply,  and  the  final  dis- 
posal of  the  matters  removed  is  still  a  difficult  problem.  If  the  cesspools  are 
leaky,  the  surrounding  soil  becomes  polluted,  affecting  the  soil  air  and  the  soil 
\vater,  which  are  liable  to  contain  specific  disease-germs  and  are  certain  to  con- 
tain unpleasant  gases  and  vapors.  Taking  cities  of  the  same  size  and  density 
of  population,  the  annual  death-rate  in  the  unsewered  cesspool  cities  is  from  3 
to  8  per  1000  greater  than  it  is  in  sewered  cities.  For  cities,  and  especially 
for  large  cities,  the  best  method  for  removing  the  sewage  is  by  water-carriage 
in  a  system  of  watertight  channels  or  sewers.  For  suburban  residences, 
country  institutions,  temporary  encampments,  and  in  very  cold  climates  the 
so-called  dry  systems  of  sewage-removal  may  be  used  :  where  there  is  no  sys- 
tem of  sewers  with  which  to  connect,  earth-closets  are  the  best  for  this  pur- 
pose, as  a  rule. 

When  sewage  is  removed  by  water-carriage,  it  may  be  finally  disposed  of 
by  allowing  it  to  flow  into  a  neighboring  stream  or  large  body  of  fresh  or  salt 
water ;  by  s])reading  it  over  the  surface  of  land  for  the  purpose  of  fertilizing 
it  and  of  raising  crops,  which  is  known  as  broad  irrigation  or  sewage  farming ; 
by  spreading  it  beneath  the  surface  of  land  through  a  system  of  small,  open- 
jointed  earthen  pipes,  which  is  called  subsurface  irrigation ;  by  filtering  it 
through  soil;  by  treating  it  with  various  chemicals  to  purify  it;  and  by  com- 
binations of  these  methods. 

The  turning  of  sewage  into  a  stream  or  lake  is  often  the  cheapest  method, 
so  far  as  immediate  cost  is  concerned  ;  but  it  dangerously  pollutes  the  water, 
is  generally  undesirable,  and  is  becoming  more  so  as  the  country  becomes  more 
thickly  settled. 

Sewage  farming  is,  theoretically,  the  best  means  of  sewage  disposal  where 
a  sufficient  quantity  of  suitable  land  is  available,  because  it  uses  the  sewage  as 
a  fertilizer,  and  thus  utilizes  the  stored  force  in  its  nitrogen  compounds.  This 
form  of  stored  force  is  essential  to  vegetation,  and  therefore  to  animal  life ;  the 
amount  of  it  in  and  on  the  earth  is  limited,  and  when  destroyed  it  is  not  easily 
rej)laced.     It  steadily  diminishes  in  a  soil  cultivated  without  fertilizers. 

At  present  the  commercial  value  of  sewage  as  a  fertilizer  is,  in  most  locali- 
ties, insufficient  to  repay  the  cost  of  its  collection  and  application ;  but  as 
population  increases  and  the  price  of  fertilizers  rises  the  value  of  sewage  will 
increase.  To  obtain  satisfactory  purification  and  fair  returns  from  crops  the 
amount  of  land  required  for  sewage  farming  is  1  acre  to  from  75  to  150  per- 
sons, depending  on  the  porosity  of  the  soil  and  the  depth  above  the  level  of  the 
subsoil  water. 

Subsurface  irrigation  is  especially  useful  for  country  houses,  asylums,  etc., 


HOUSE  SEWERAGE.  35 

where  tlicre  is  a  slope  from  the  bnikliiiii;  to  suitable  ground  adjacent,  of  wiiifh 
1  acre  is  sufficient  for  the  sewage  from  75  persons. 

The  slow,  intermittent  filtration  of  sewage  through  sand,  in  such  a  manner 
as  to  promote  the  growth  throughout  the  filter  of  masses  of  nitrifying  organisms 
is  at  present  one  of  the  best  known  methods  of  sewage-ilisposal.  The  applica- 
tion of  the  sewage  must  be  intermittent,  so  that  there  shall  always  be  abundance 
i)f  air  in  the  filter.  Each  acre  of  such  a  filter,  properly  constructed  and  man- 
aged, will  purify  the  sewage  coming  from  about  1000  persons;  and  the  fluid 
which  escapes  from  it  will  be  a  clear,  odorless  water,  containing  inorganic  salts 
in  solution,  not  susceptible  of  putrefaction,  and  free  from  sj)ecific  pathogenic 
bacteria  and  their  dangerous  products. 

Bv  the  addition  of  various  chemicals,  such  as  lime,  alum,  sulphate  of  iron, 
etc.,  about  one-half  of  the  organic  matter  and  a  considerable  pro])ortion  of  the 
bacteria  of  sewage  may  be  removed ;  but  the  results  are  not  as  satisfactory  as 
those  obtained  by  intermittent  filtration,  and  it  is  more  costly. 

Sewers  may  be  constructed  to  receive  only  the  water  fouled  by  use  in  habi- 
tations, forming  what  is  called  a  separate  system  ;  or  to  receive  also  the  water 
of  rainfall  from  roofs,  yards,  and  streets,  forming  what  is  known  as  the  com- 
bined svstem.  Most  large  cities  have  the  combined  system.  The  separate 
system  has  its  collecting  branches  made  of  pipes  from  six  to  twelve  inches  in 
diameter,  laid  with  watertight  joints ;  it  is  much  cheaper  in  construction  than 
the  combined  system,  and  is  specially  applicable  to  localities  where  the  pro- 
portion of  length  of  street  to  number  of  houses  is  large,  as  in  villages  and 
small  towns.  It  is  desirable  where  the  sewage  is  to  be  disposed  of  by  irriga- 
tion or  filtration,  as  the  amount  of  sewage  should  be  as  constant  as  possible  in 

such  cases. 

To  keep  sewers  in  good  condition  and  free  from  foul  odors  the  sewage  must 
be  delivered  to  them  fresh,  and  not  as  an  overflow  from  a  cesspool ;  the  grades 
must  be  such  as  to  secure  a  constant  flow  and  to  prevent  stagnation  of  the 
liquid  at  any  point;  and  they  must  be  well  ventilated. 

The  good  effects  of  sewers  on  i\\Q  health  of  a  town  are  due  not  only  to  the 
removal  of  sewage,  but  to  the  fact  that  they  act  also  as  drains,  and  tend  to 
prevent  the  subsoil  water  from  rising  above  the  level  at  which  they  are  laid. 
This  is  true  even  where  they  are  watertight  tubes,  as  drainage  takes  place 
through  the  loose  soil  immediately  surrounding  them. 

House  Sewerage. 
The  main  pipes  placed  in  a  house  for  the  removal  of  excreta  are  called  soil 
pipes,  and  these,  with  the  pipes  and  fixtures  co..nc(;ted  with  thcni,  arc  usmmUv 
.spoken  of  as  forming  the  system  of  house  drainage.  It  is  Letter,  however,  to 
restrict  the  ti-rm  ''drainage"  to  the  removal  of  surface;  and  soil  water,  and  to 
<-all  the  system  al)ove  reCerre.l  to  that  of  house  sewerage.  It  consists  ol'  lixlures, 
sueh  as  water-closets,  urinals,  slop-sinks,  bath-tubs,  kit<-l.en-sinl<s,  wash-tul.s, 
(■te.,  of  the  waste  i>ipes  leading  from  them,  of  cisterns  or  tanks  lor  ll„.-lung 
them   of  traps,  of  special  ventilating  pipes,  and  of  the  soil  pipes  as  lar  as  fl.eir 


36  HYGIENE. 

connection  with  a  sewer  or  cesspool  outside  the  house.  The  essential  feature 
of  a  satisfactory  system  is  that  no  air  from  the  interior  of  the  waste  or  soil 
pipes  or  from  the  sewer  shall  escape  into  the  house  or  into  any  part  of  its 
water-supply ;  that  all  foul  matters  turned  into  the  system  shall  be  washed 
rapidly  away  without  stagnation  at  any  point ;  that  the  liability  to  obstruction 
of  any  of  the  pipes  shall  be  as  small  as  possible;  and  that  if  it  does  occur  it 
can  be  easily  located  and  removed.  It  is  moreover  desirable  that  the  waste 
and  soil  pipes  shall  have  a  constant  gentle  current  of  fresh  air  passing  through 
all  parts  of  them  as  far  as  possible,  in  order  to  favor  the  growth  of  the  aerobic 
bacteria  in  the  slime  which  lines  them,  and  thus  to  prevent  the  development 
of  those  organisms  which  produce  foul  odors  as  well  as  of  those  which  cause 
disease,  as  explained  in  the  section  on  Sewage-disposal.  All  this  requires  a 
proper  plan  of  arrangement  and  connections,  good  materials  and  good  work- 
manship, and  care  in  use,  with  occasional  skilled  inspection  to  make  sure  that 
all  the  parts  remain  in  good  order.  From  such  a  system  there  is  no  special 
danger  to  health.  As  regards  plan  and  arrangements,  the  plumbing  regula- 
tions of  most  of  our  large  cities  are  now  fairly  in  accord  and  are  satisfactory, 
the  main  points  being  as  follows  : 

1.  Soil  pipes  must  be  extra  heavy  cast-iron  or  standard  wrought-iron  pipe, 
not  less  than  four  inches  in  diameter  and  free  from  cracks,  holes,  and  other 
defects  ;  they  must  have  a  continuous  fall  toward  the  sewer  and  must  be  so  put 
together  as  to  be  air-  and  water-tight  at  all  joints. 

2.  Soil  pipes  must  be  extended  fidl  size  up  to  and  through  the  roof,  and  be 
freely  open  to  the  outer  air  at  the  top. 

3.  It  is  not  desirable  that  the  sewers  should  be  ventilated  through  the  soil 
pipes  or  through  rain-water  pipes  in  any  case  where  the  air  escaping  at  the 
top  of  the  pipe  is  liable  to  enter  a  window  of  the  same  or  of  an  adjacent  house. 
In  most  cases  it  is  better  to  cut  off  the  sewer  air  from  the  soil  pipe  by  a  trap 
between  the  house  and  the  sewer,  and  to  provide  a  fresh-air  inlet  to  the  soil  pipe 
just  inside  of  this  trap. 

4.  Every  fixture  should  have  a  trap  on  its  waste  pipe  fixed  as  close  to  it 
as  possible,  and  from  the  top  of  this  trap  there  should  be  a  ventilating  pipe  of 
a  size  not  less  than  that  of  the  waste  pipe  to  which  the  trap  is  attached,  which 
ventilating  pipe  should  continuously  incline  upward  and  open  above  the  roof. 
A  mechanical  trap  which  merely  prevents  siphonage  is  not  a  satisfactory  sub- 
stitute for  the  ventilation  of  the  trap  and.  waste  pipe. 

5.  All  water-closets  or  slop-sinks  should  be  flushed  from  a  special  tank  or 
cistern,  and  never  directly  from  a  water-supply  pipe. 

6.  Waste  pipes  from  refrigerators,  from  safes  placed  beneath  fixtures,  or 
from  tanks  or  cisterns  except  flushing  tanks,  should  not  be  connected  with  soil 
pipes,  but  should  discharge  in  the  open  air. 

7.  The  arrangement  of  the  waste,  ventilating,  and  soil  pipes  should  be  such 
that  they  can  readily  be  inspected  at  all  points. 

About  half  of  the  houses  having  a  sewerage  system  have  one  with  defects 
in  it  of  some  kind  which  permit  of  the  occasional  discharge  of  soil-pipe  air  into 


VEXTILA  riOX.  37 

the  house ;  lience  the  discovery  of  such  a  defect  in  a  house  in  \vliicli  there  is 
sickness  is  no  proof  tliat  the  latter  is  caused  by  the  former.  In  a  well-sewered 
house  the  chief  danj^er  to  health  connected  with  the  system  occurs  when  the 
fixtures  have  been  unused  for  two  or  three  months,  and  the  traps  and  interior 
of  the  pipes  have  become  dry,  so  as  to  give  oil' dust-particles  which  are  carried 
into  the  rooms.  The  best-water  closet  is  one  of  the  all-porcelain  wash-out 
forms,  of  which  several  varieties  are  in  the  market.  The  worst  form  is  the 
pan  closet.     Trapless  closets  should  be  avoided. 

Ventilation. 

Most  persons  of  average  cleanly  habits  in  this  country  would  object  to 
being  compelled  to  wear  under-clothing  that  had  just  been  removed  from  the 
body  of  another  man,  or  to  use  another  person's  toothbrush,  or  to  cat  food 
that  had  been  partially  masticated  by  another.  They  do  not,  however,  often 
object  to  drawing  into  their  noses,  mouths,  and  lungs  air  that  has  very 
recently  been  inside  anotlicr  man's  body ;  and  upon  the  whole  it  is  fortunate 
that  they  do  not,  for  they  cannot  very  well  help  doing  so  under  the  ordinary 
conditions  of  civilized  life.  The  evil  results  of  the  continuous  inhalation  of 
impure  air  are  not,  in  most  cases,  such  as  to  attract  notice  unless  the  impurity 
is  very  considerable  or  the  conditions  of  moisture  and  temperature  connected 
with  it  are  such  as  to  produce  evident  discomfort.  The  injury  inflicted  on  the 
bodv  by  breathing  air  deficient  in  oxygen  and  contaminated  with  animal 
exhalations  is  usually  not  perceptible  until  after  a  considerable  period  of  time, 
and  is  then  often  attributed  to  other  causes.  The  proof  that  this  injury  occurs 
has  been  obtained  by  comparison  of  the  statistics  of  disease  for  a  series  of 
years  among  men  living  in  unventilated  with  those  of  men  living  in  well-ven- 
tilated barracks,  ])risons,  etc.,  and  also  among  cavalry  horses  kept  in  well-  and 
ill-ventilated  stables.  The  diseases  which  are  especially  produced  or  aggra- 
vated by  defective  ventilation  are  chronic  inflammatory  affections  of  the  throat 
and  lungs  and  certain  forms  of  contagious  disease,  more  especially  typhus 
fever  and  phthisis.  With  regard  to  phthisis,  this  is  due  in  part  to  the  fact 
that  the  probabilities  of  inhaling  the  specific  bacillus  or  its  spores  are  greater 
where  a  number  of  men  or  animals  are  repeatedly  breathing  air  cotitaining  the 
dried  sputa  and  other  excretions  of  their  companions,  and  partly  because  the 
inhaling  of  air  loaded  with  dead  or  dying  organic  matters  tends  to  accinnulate 
in  the  air-passages  materials  well  suited  Wn-  the  nonrishnu'ut  of  the  specific 
germs,  which  in  the  absence  of  such  food-material  would  be  killed  by  the  liv- 
in<r  tissues  with  which  thev  would  come  in  contact. 

In  ordinarv  life  it  is  difficult  or  impossible  to  sc|)arate  the  efl'ccts  of  impure 
air  from  those  of  insufficient  or  improper  food  or  clothing,  or  from  those  of 
general  want  and  cleanliness,  as,  for  instance,  in  yfiidying  the  causes  of  the 
excessive  mortality  in  a  dense  population,  as  in  a  tenement-house;  but  if  the 
importance  of  respiration  to  life,  the  immense  surface  which  llic  uir-passages' 
and  air-cells  present  for  the  lodgment  of  particles,  and  the  favorable  con- 
ditions which  these  present  for  the  growth  of  bacteria  so  far  as  moisture  and 


38  HYGIENE. 

temperature  are  concerned,  be  considered,  it  is  evident  that  the  purity  or 
impurity  of  the  air  breathed  must  be  an  important  factor  in  the  preservation 
or  loss  of  health  and  energy. 

Ventilation  is  the  continuous  and  more  or  less  systematic  changing  or 
renewal  of  the  air  in  a  room  or  other  enclosed  space.  It  may  be  used  to 
remove  watery  vapor,  as  from  damp  walls  or  from  the  drying-room  of  a  fac- 
tory, or  to  remove  dust  or  oifensive  or  dangerous  gases  or  vapors  produced  in 
certain  manufacturing  operations;  but  it  is  usually  provided  for  the  purpose 
of  diluting  and  removing  the  products  of  exhalation  and  respiration  of  man 
and  to  regulate  the  temperature  of  apartments.  To  eflPect  it  the  external  air 
must  be  introduced  in  a  continuous  current  and  diffused  throughout  the  room, 
and  a  corresponding  quantity  of  air  must  be  continuously  taken  out. 

As  a  rule,  we  must  take  the  outer  air  as  we  find  it :  at  night  we  must  use 
night  air;  in  cities  we  must  take  it  from  the  streets.  It  is  true  that  by  special 
appliances  we  can  draw  the  air  down  through  a  tower  and  can  filter  it  through 
cotton  or  through  water-spray,  but  this  is  rarely  necessary. 

Perfect  ventilation  would  ensure  that  a  nian^  inhaled  no  air  which  had 
recently  been  in  his  own  lungs  or  in  those  of  his  companions.  Good  ordinary 
ventilation  does  not  aim  at  this  perfection  :  it  merely  ensures  that  the  fresh  air 
comes  in  in  sufficiency,  and  is  so  thoroughly  mixed  with  the  air  in  the  room 
that  the  products  of  exhalation  and  respiration  are  so  diluted  that  when  a  man 
having  a  normal  sense  of  smell  comes  into  the  room  from  the  outside  air  he 
will   perceive  no  unpleasant  odor. 

The  matters  given  off  from  the  skin  and  lungs  consist  of  carbonic  acid, 
watery  vapor,  dried  epithelial  scales,  and  certain  nitrogenous  products  of 
decomposition  belonging  to  the  ammonia  and  amine  groups.  It  is  these  last 
which  are  the  source  of  danger  and  of  odor.  The  carbonic  acid  has  no  odor, 
and  in  the  proportion  in  which  it  exists  in  a  crowded,  unventilated  room  is  not 
dangerous,  but  it  increases  in  proportion  to  the  dangerous  nitrogenous  matters; 
its  amount  is  easily  measured,  and  hence  we  judge  of  the  effects  of  ventilation 
by  the  proportion  of  carbonic  acid  found  present.  This  proportion  should  not 
exceed  2  parts  in  10,000  over  and  above  the  amount  which  was  in  the  air 
when  it  entered  the  room.  If  the  air  enters  the  room  directly  from  the  outer 
air,  it  will  usually  contain  from  3  to  4  parts  of  carbonic  acid  per  10,000,  and 
in  that  case,  if  the  room  is  well  ventilated,  the  proportion  will  not  exceed  6 
parts  in  10,000  in  the  air  in  any  part  of  the  room.  But  if  the  air  has  come 
from  the  cellar  or  through  an  underground  passage,  it  may  contain  from  7  to 
12  parts  of  COg  per  10,000  as  it  enters  the  room  ;  and  this  should  be  con- 
stantly borne  in  mind  in  attempting  to  measure  the  amount  and  completeness 
of  the  ventilation  of  an  apartment  by  means  of  carbonic  analysis. 

The  great  majority  of  people  suppose  that  ventilation  means  simply  the 
removal  of  foul  air,  and  that  this  can  be  effected  by  putting  in  some  kind  of 
an  opening,  or  tube,  or  flue  through  which  the  foul  air  will  either  flow  out  or 
may  be  forced  out.  In  very  few  private  dwellings,  even  large  and  costly  ones, 
arc  there  any  special  provisions  for  the  admission  of  fresh  air  to  the  several 


VENTILA  TIOX.  39 

rooms,  and  in  the  immense  majority  of  scliool-rooms,  lecture-rooms,  theatres, 
and  other  places  of  public  assembly,  either  there  are  no  special  arrangements 
for  the  supply  of  fresh  air,  or  these  are  entirely  insufficient  for  the  purj)()se. 

Tiie  amount  of  fresh-air  supply  required  tor  a  room  depends  upon  tlie  num- 
ber of  people  wlu)  are  to  occu])y  it,  and  whether  it  is  to  be  occupied  only  an 
hour  or  two  at  a  time,  or  for  several  consecutive  hours,  or  permanently.  In  a 
hospital  ward  which  is  permanently  occupied  and  which  requires  the  most,  the 
air-supply  should  be  not  less  than  1  cubic  foot  per  second  per  bed,  or  3600 
cubic  feet  per  hour  per  person.  For  bed-rooms,  barrack-rooms,  prison-cells, 
etc.  the  supply  should  be  3000  cubic  feet  per  hour  per  head.  For  school- 
rooms, lecture-rooms,  etc.,  which  can  be  thorouirhly  aired  out  after  two  hours' 
occupancy,  the  supply  may  be  from  2000  to  2400  cubic  feet  per  hour  per  head. 
If  double  or  triple  these  quantities  can  be  furnished,  so  much  the  better,  but 
as  a  rule  this  can  only  be  done  in  warm  weather,  when  the  windows  can  be 
left  freely  open.  The  reason  for  this  is  that  in  cold  weather  the  room  must  be 
kept  warm,  and  the  larger  the  amount  of  air  that  is  passed  through  it  the  more 
fuel  it  takes  to  heat  it. 

If  a  room  is  warmed  by  hot  air  brought  into  it  by  flues  and  registers,  as 
from  a  furnace  or  from  steam  or  hot-water  radiators  in  tlie  cellar,  it  is  said  to 
be  heated  bv  indirect  radiation.  If  the  heating  surfaces  are  in  the  room  itself, 
it  is  said  to  be  heated  by  direct  radiation,  and  in  this  case  no  arrangements  are 
usually  made  for  warming  the  incoming  fresh  air,  or  indeed  for  providing  any 
fresh  air  at  all.  If,  however,  fresh  air  is  brought  in  so  as  to  surround  and  be 
warmed  by  the  stove,  the  back  of  the  fireplace,  or  the  steam  radiator,  the  room 
is  said  to  be  heated  by  the  direct-indirect  method. 

To  get  the  requisite  amount  of  fresh  air  into  the  room,  flues  and  registers 
of  sufficient  size  nnist  be  provided,  and  if  the  room  be  a  large  one,  they  should 
be  at  several  diflerent  points,  in  order  to  secure  a  good  mixture  of  the  fresh 
with  the  foul  air.  The  velocity  of  the  air  in  the  flues  should  be  from  4  to  (5 
feet  per  second  ;  as  it  comes  through  the  register  it  should  not  exceed  4  feet  per 
second.  The  usual  rule  is  to  allow  about  24  square  inches  per  head  for  the 
inlets — that  is,  1  square  foot  for  six  persons — but  this  is  a  scant  allowance, 
especially  for  hospitals.  In  a  hospital  ward  for  twenty-four  beds  the  comliiiicd 
area  of  the  inlet  flues  should  be  at  least  G  scpiare  feet. 

In  rooms  heated  bv  indirect  radiation  the  only  way  in  which  the  temperature 
can  be  lowered  if  it  gets  too  hot  is,  in  most  cases,  to  close  the  register  and  so 
shut  off  the  sui)ply  of  fresh  air,  or  else  to  open  the  window,  which  is  often 
undesirable.  In  a  pro})erly-constructed  heating  ap|)aratus  there  is  a  by-pass 
around  the  radiator,  so  that  by  moving  a  valve  the  (Ve-li  air  can  either  be 
brought  around  it  or  through  it,  and  be  admitted  cold,  uv  li«it,  or  al  any  desired 
temperature,  so  that  the  register  need  never  i)e  closed. 

In  the  direct-indirect  method,  if  tiie  healing  is  l)y  steam  or  hot  water,  the 
usual  position  of  the  radiators  is  in  the  wiii< low-breast,  and  the  air  is  admitted 
beneath  the  window-sill  ;  if  by  stoves,  the  :iir  is  brought  in  through  an  air- 
box  placed  beneath  the  floor,  one  end  open  to  ihr  outer  :ur,  the  other  opening 


40  HYGIENE. 

beneath  the  stove,  which  is  surrounded  by  a  jacket  of  tin,  or  sheet  iron,  to 
force  the  air  to  ascend  along  the  sides  of  the  hot  stove.  This  method  is  per- 
haps the  best  for  country  school-houses. 

In  the  direct  method  the  heat  is  supplied  by  an  open  fire  or  by  some  kind 
of  stove  or  radiator,  and  the  fresh  air  is  admitted  at  some  other  point  or  points 
and,  is  not  warmed.  In  this  case  the  opening  for  the  incoming  air  should  be 
so  placed  and  shaped  that  the  current  will  be  directed  upward  toward  the  ceil- 
ino-.  The  simplest  mode  of  doing  this  is  by  raising  the  lower  sash  of  the  win- 
dow four  inches,  closing  the  opening  thus  formed  by  a  board,  and  allowing  the 
air  to  come  in  through  the  crevice  thus  formed  between  the  upper  and  lower 
sashes.  In  most  houses  the  fresh-air  supply  comes  in  through  crevices  about 
the  doors  and  windows,  through  the  cellar  from  the  soil  into  the  halls  and 
stairways,  and  directly  through  the  walls  of  the  house.  Through  the  outer 
wall  of  an  ordinary  brick  house,  plastered  but  not  painted  or  papered,  about 
7  cubic  feet  of  air  to  each  square  yard  pass  per  hour  if  the  room  is  ten  degrees 
warmer  than  the  outer  air.  If  the  wall  is  damp,  or  is  painted  or  papered  on 
the  inside,  very  little  air  can  go  through  it.  Stone  walls  are  much  less  pervious 
to  air  than  brick  ones. 

In  most  dwelling-houses  the  outlets  for  foul  air  are  the  chimney-flues,  and 
if  the  room  have  an  open  fireplace  connected  with  such  a  flue,  it  is  in  most 
cases  sufficient,  even  if  there  be  no  fire  in  the  fireplace.  In  hospitals,  schools, 
and  other  rooms  where  a  number  of  persons  are  assembled,  special  outlet  flues 
should  be  provided.  The  movement  of  the  air  tiirough  the  room  and  in  these 
outlet  flues  is  generally  produced  by  the  difference  in  temperature  between  the 
air  in  the  room  and  that  of  the  outer  air.  Air  expands  1  part  in  491  of  its 
volume  for  each  degree  Fahrenheit  that  it  is  heated,  and,  if  it  is  free  to  expand, 
a  cubic  foot  of  warm  air  is  therefore  lighter  than  a  cubic  foot  of  cold  air.  The 
result  of  this  is  that  the  heavier  cold  air  tends  to  flow  in  below  and  push  up 
the  lighter  warm  air.  The  pressure  thus  produced  depends  on  the  height  of 
the  column  of  warm  air,  being  equal  to  this  height  multiplied  by  the  difference 
in  temperature  between  the  warm  and  cold  air  divided  by  491,  and  the  velocity, 
if  there  is  no  friction,  equals  eight  times  the  square  root  of  this.  Thus,  if  the 
height  from  the  fireplace  to  the  top  of  the  chimney  is  20  feet,  and  the  difference 
in  temjierature  between  the  air  of  the  room  and  the  outer  air  is  20°  F.,  the 
theoretical  velocity  of  the  upward  flow  of  the  air  in  the  chimney-flue  would 

be  -^- ,  or  a  little  over  7  feet  per  second.     The  actual  velocity  will 

depend  on  the  amount  of  friction  at  the  points  of  entrance  of  the  air  into 
the  room  and  in  the  outlet  flue.  If  one  fourth  be  deducted  for  this,  the 
velocity  in  the  above  case  would  be  5.38  feet  per  second.  If  the  flue  were  1 
foot  square  in  cross-section,  5.38  cubic  feet  of  air  would  pass  through  it  every 
second. 

If  the  air  in  the  flue  and  room  is  colder  tiian  the  external  air,  it  will  fall 
instead  of  rising;  the  current  will  be  reversed.  It  is  not  desirable  to  place 
upcast  flues  in  outer  walls,  for  the  air  in  them  is  liable  to  be  chilled  and  the 


VENTILA  TION.  41 

upward  current  checked.  It  is  also  not  desirable  to  liave  two  or  more  separate 
upcast  flues  in  a  room,  for  the  cold  air  is  liable  to  flow  down  one  of  them,  so  that 
it  becomes  an  inlet  instead  of  an  outlet.  The  velocity  of  the  air  in  an  ordinary 
smoke  or  ventilating  upcast  flue  should  be  about  6  feet  per  second  to  produce 
the  best  and  most  economical  results.  At  the  top  of  the  flue  it  is  best  to  have 
a  little  greater  velocity,  say  8  feet  per  second,  to  prevent  possible  interference 
by  the  wind.  The  area  of  the  outlet  flues  should  therefore  be  about  the  same 
as  that  of  the  inlet  flues,  giving  from  24  to  36  scpiare  inches  per  head. 

The  movement  of  air  necessary  for  ventilation  may  be  produced  not  only  by 
the  ordinary  differences  of  temperature  betwe'en  the  exterior  and  interior  of  a 
building,  but  by  wind  ;  by  heat  specially  a])plied  for  the  purpose,  as  by  steam- 
pipes,  furnaces,  gas-jets,  etc.;  by  steam-  or  water-jets;  or  by  fans  ami  pro- 
pellers of  various  kinds  moved  by  machinery.  The  special  mechanical  means 
for  forcing  air  in  or  drawing  it  out  are  only  used  in  mines,  tunnels,  and  large 
public  buildings.  Wind  is  an  important  aid  to  ventilation,  but  is  not  to  be 
relied  upon.  In  warm  weather,  when  doors  and  windows  can  be  freely  ojiened, 
nothing  can  take  its  place,  but  when  these  are  closed  it  produces  its  effects  either 
by  increasing  the  inward  flow  of  air  through  crevices,  walls,  etc.,  or  by  modi- 
fying the  flow  through  upcast  shafts,  its  efl'ects  depending  on  the  position  and 
shape  of  the  openings  at  the  top  of  these  shafts  and  on  the  velocity  of  the 
current  escaping  from  them.  As  a  rule,  the  top  of  an  exit  ventilating 
flue  or  shaft  should  be  covered  in  such  a  way  as  to  prevent  the  entrance 
of  rain  or  snow,  for  if  the  wall  of  the  flue  is  damp,  mndi  heat  is  taken  up 
in  the  eva])oration  of  the  water  and  the  ascending  current  is  thus  chilled 
and  checked. 

To  secure  good  ventilation  in  a  room  it  is  necessary  not  only  to  introduce 
and  remove  the  requisite  quantity  of  air,  but  to  secure  a  thorough  distribution 
and  mixing  up  of  the  air  in  the  room,  and  to  do  this  without  causing  draughts 
which  will  be  unpleasant  to  the  inmates.  Air  has  a  strong  tendency  to  adhere 
to  surfaces  against  which  a  current  of  it  strikes  :  it  docs  not  rebound  like  a 
billiard  ball  from  a  cushion,  but  spreads  out  in  a  thin  sheet  on  the  sm-face  of 
the  wall,  roof,  ceiling,  or  floor  against  which  it  iuipinges.  When  it  becomes 
chilled  affainst  the  surface  of  a  window,  it  flows  downward  in  a  thin  sheet, 
giving  the  sensation  to  one  seated  by  it  of  a  curn>iit  of  cold  air  h'aking  in 
throu<di  the  sash.  If  fresh  warm  air  be  introduced  tiirough  registers  in  (he 
floor,  it  rises  directly  to  the  ceiling,  where  it  spreads  out,  and  gradually 
descends  as  it  becomes  chilled.  A  liviug  man  is  usually  from  (wcniy  (<>  thirty 
degrees  warmer  tliaii  the  air  of  his  room  in  winter,  ami  therefore  acts  as  a  little 

stove,  causing  an  ascending  current  of  air.     The  ;iir  which  1 xliales  is  also 

warnur  than  the  siin-oiuiding  air,  :iiid  rises.  It  is  frne  that  it  contains  more 
carbonic  acid  than  the  surrounding  air,  and  tliat  carbonic  a.id  is  Iieavier  than 
air  of  the  same  temperature,  but  as  dihite.l  and  warni<'<i  in  (he  breath  i(  is 
lighter.  There  is  no  accumulation  of  earbonic  acid  near  (he  Ihx.r  <>{'  ;m 
inhabited  room.  V<'ntilation  dibit<'s  (he  gases  and  va|)ors  in  a  n.oin,  but  it 
has  not  nnich  eflec^t  on  the  suspended   |)articles,  inclu<iing  bacteria,  except  for 


42  HYGIENE. 

a  few  moments  after  a  dust  has  been  raised.     Ordinarily,  unless  specially 
filtered,  it  brings  in  about  as  many  bacteria  as  it  takes  out. 

The  ventilation  of  soil  pipes  is  referred  to  in  the  section  relating;  to  House 
drainage.  To  test  the  sufficiency  of  the  ventilation  of  a  room  the  determina- 
tion of  the  proportion  of  carbonic  acid  in  the  air  in  different  parts  of  the  room, 
as  compared  with  that  in  the  air  as  it  enters  the  room,  is  the  best  method.  To 
determine  the  amount  of  air  entering  and  leaving  the  room  by  the  special  sup- 
ply and  exit  flues,  an  instrument  called  an  anemometer  is  used  to  measure  tiie 
velocity  of  the  current  in  feet  per  second,  and  this  velocity,  multiplied  by  the 
area  of  the  flue  or  opening,  stated  in  square  feet  and  fractions  of  a  square  foot, 
gives  the  number  of  cubic  feet  passing  per  second.  Most  anemometers  will 
not  record  a  velocity  of  less  than  2  feet  per  second.  The  direction  of  currents 
in  the  room  is  determined  by  toy  balloons,  by  smoke,  and  by  the  fumes  of 
nascent  muriate  of  ammonia.  So  far  as  the  impurities  due  to  respiration  and 
exhalation  from  the  skin  are  concerned,  the  normal  sense  of  smell  gives  a  good 
test,  for  if  no  odor  is  perceived  when  first  entering  from  the  outer  air  the  venti- 
lation is  good.  Care  must  be  taken  not  to  confuse  the  sense  of  discomfort 
created  by  an  excessively  warm  and  moist  air  with  that  due  to  an  excess  of 
organic  im})urities ;  a  hot  moist  air  may  be  pure,  and  a  cool  air  very  impure. 

Disposal  of  the  Dead. 
For  the  great  majority  of  American  communities  the  best  method  of  dis- 
posing of  the  dead  is  to  bury  them  in  the  ground  in  such  a  way  as  to  favor 
their  decomposition  into  gases,  water,  and  soluble  salts.  No  attempt  should  be 
made  to  preserve  the  bodies,  as  by  embalming,  by  the  use  of  metallic  coffins, 
etc.  Under  ordinary  circumstances  there  is  no  reason  to  believe  that  cem- 
eteries are  a  source  of  danger  to  those  who  live  in  the  vicinity,  or  that  they 
cause  dangerous  pollution  to  water-supplies.  Overcrowded  and  badly-managed 
cemeteries  in  the  midst  of  large  cities  have  in  times  gone  by  produced  nuisance 
and  ])erha])s  disease,  but  this  is  not  a  valid  objection  to  the  ordinary  methods 
of  burial  in  rural  cemeteries.  A  cemetery  is  not  a  nuisance  per  se,  but  a  leg- 
islature has  a  right  to  pass  laws  regulating  interment  both  in  private  and  pub- 
lic burying-grounds,  and  it  has  the  right  to  forbid  the  continued  use  of  any 
piece  of  ground  for  burial  purposes  and  to  order  the  removal  of  the  bodies 
already  buried  therein.  The  arguments  in  favor  of  cremation  are  in  the  main 
theoretical,  or  appeal  to  the  emotions  ratlier  tlian  to  reason  ;  on  the  other  hand, 
the  chief  objections  that  have  been  made  to  cremation,  as  that  it  destroys 
stored  force  that  came  from  the  soil  and  should  be  given  back  to  it,  or  that  it 
destroys  the  evidence  of  crime,  are  also  theoretical  and  of  little  value.  The 
chief  dangers  and  discomforts  which  the  dead  cause  to  the  living  occur  prior 
to  burial  in  preserving  the  bodies  and  in  connection  with  funerals.  In  the 
crowded  habitations  of  tlie  ])oor  the  keeping  of  dead  bodies  among  the  living 
for  several  days  prior  to  burial  causes  much  discomfort  and  sometimes  danger. 
Each  city  should  have  a  public  mortuary  where  the  dead  can  be  properly 
cared  for  prior  to  interment.     In  all  cases  of  death  from  contagious  disease 


SAXITABY  JURISPRUDENCE.  43 

the  funeral  should  be  as  private  as  possible,  and  there  should  be  no  gathering 
of  friends  in  the  infected  house.  Funeral  processions  and  parades  are 
invariably  more  or  less  injurious  to  all  concerned,  are  a  heavy  burden  on  the 
poor,  and  in  cold  or  stormy  weather  are  a  fruitful  cause  of  disease. 

Sanitary  Jurisprudence. 

Constant  yielding  to  the  appetites  and  desires  of  the  moment  cannot  be 
indulged  in  Avith  safety  to  the  health  of  the  individual,  and  in  like  manner  in 
a  community  a  certain  amount  of  personal  individual  liberty  nnist  be  sur- 
rendered to  preserve  the  healtli  and  comfort  of  the  mass  of  the  people.  That 
the  State,  when  it  does  act,  should  do  so  with  regard  to  the  interests  of  the 
many  rather  than  of  individuals  is  the  theoretical  rule,  but  the  practical  ques- 
tion is,  often  :  To  what  extent  is  it  best  to  allow  the  community  to  suffer  in 
order  not  to  interfere  with  individual  benefits?  and  the  answer  to  this  differs 
greatly  for  different  places  and  at  different  times. 

As  a  general  rule,  in  the  United  States,  the  power  to  control  nuisances  and 
to  regulate  matters  affecting  health  depends  upon  what  is  called  the  police 
power  of  the  several  States,  which  is  exerted  cither  through  specific  enactments 
by  State  legislatures,  forming  what  is  called  statute  law ;  tlirough  rules  and 
regulations  framed  by  munici})al  or  other  local  authority  in  accordance  with 
State  legislation  ;  or  through  the  interpretation  by  the  courts  of  statutes  or  of 
prevailing  customs,  forming  what  is  called  the  common  law. 

That  part  of  the  common  law  which  relates  to  jniblic  hygiene  is  summed 
up  in  what  is  called  the  law  of  nuisance  as  set  fortli  in  the  decisions  of  the 
courts,  which  are  based  on  the  principle  that  a  man  must  so  use  his  liberty  of 
action  and  his  property  as  not  to  cause  injury  to  the  health  of  others.  The 
most  difficult  and  doubtful  point  in  the  application  of  this  principle  is  to 
determine  the  cases  in  which  an  individual  is  entitled  to  compensation  for 
restriction  of  his  liberty  for  the  public  benefit. 

Under  what  is  called  the  "  right  of  eminent  domain  "  the  government  may 
demand  the  services  of  any  of  its  citizens  or  may  take  private  property  for 
the  public  good,  but  it  must  furnish  a  reasonable  compensation  for  the  ser- 
vice or  propcrtv  thus  taken.  But  under  what  is  called  tlie  ])olice  power  it  is 
usually  held  that  certain  uses  of  property  may  be  forbidden,  or  certain  services 
required  by  the  State,  without  entitling  the  person  whose  liberty  is  thus 
restricted  to  compensation  therefor.  This  is  the  case  with  regard  to  laws  pro- 
hil)iting  the  storage  of  gunpowder  near  habitations  or  highways,  or  forbidding 
the  erection  of  wooden  buildings  in  certain  parts  of  cities,  or  requiring  that  the 
plumbing  in  a  house  shall  be  arranged  in  a  certain  way,  etc.  "  In  abating  a 
nuisance  i)roi)erty  may  be  destn.yed  and  the  owner  deprived  of  it  without 
trial,  without  notice,  and  without  {'ompensatiou.  Such  deslruetiou  for  [\\(\ 
public  safety  or  health  is  not  a  taking  of  private  i)ro|)erty  for  public  use  with- 
out compensation  or  due  i)roeess  of  law  in  the  sense  of  the  Constitution.  It 
is  simply  the  prevention  of  its  noxious  and  unlawful  w^v,  and  depends  \\\m)\\ 
the  principles  that  every  man  nuist  so  use  his  property  as  not  to   injure  his 


44  HYGIENE. 

neighbor,  and  that  the  safety  of  the  public  is  the  paramount  law.  These 
principles  are  legal  maxims  or  axioms  essential  to  the  existence  of  regulated 
society.  Written  constitutions  presuppose  them,  are  subordinate  to  them,  and 
cannot  set  them  aside."     {New  Jersey  Repts.,  8  C.  E.,  Gi-een,  p.  255). 

The  refusal  of  compensation  for  loss  to  an  individual  caused  by  action  of 
the  State  under  the  police  power  is  sometimes  in  conflict  with  the  important 
legal  principle  that  if  a  man  is  compelled  to  give  up  to  the  public  his  time, 
his  labor,  or  his  property,  or  any  value  therein,  he  has  a  right  to  demand  from 
the  public  compensation  therefor. 

Under  the  common  law  there  is  much  difficulty  in  many  cases  in  deciding 
as  to  Avhat  amount  or  degree  of  danger  or  discomfort  constitutes  a  nuisance : 
one  court  is  not  bound  by  the  decisions  of  another  one,  and  different  judges 
have  very  different  ideas  as  to  the  relative  importance  of  general  business 
interests,  of  public  health,  and  individual  rights,  and  decide  according  to  what 
they  deem  expedient  for  that  particular  place  and  time. 

For  these  and  otber  reasons  connected  with  the  uncertainty  and  cost  of 
legal  proceedings  under  the  common  law  it  is  necessary  to  have  positive,  def- 
inite statute  law  to  secure  as  clear  and  precise  definitions  as  possible  of  what 
is  forbidden  and  of  what  is  to  be  done  to  prevent  or  to  get  rid  of  nuisances. 
In  connection  with  such  regulations  it  is  usual  to  provide  some  special  nieans 
for  their  enforcement  in  the  shape  of  a  health  department,  board  of  health,  or 
liealth  officer.  The  health  department  of  a  city,  if  it  is  to  be  really  efficient, 
should  have  certain  quasi  legislative  and  judicial  as  well  as  administrative 
powers,  and  should  have  charge  of  the  registration  of  vital  statistics.  Much 
of  the  information  which  it  requires  to  enable  it  to  do  its  work  properly  must 
be  obtained  directly  or  indirectly  from  medical  men,  and  hence  the  organ- 
ization, powers,  and  duties  of  such  departments  are  of  special  interest  to 
physicians. 

A  municipal  corporation  in  making  sanitary  regulations  must  not  exceed 
the  proper  and  necessary  powers  delegated  to  it  by  the  State  legislature ;  but 
the  State  may  expressly  authorize  the  city  to  pass  local  laws  and  to  be  the 
exclusive  judge  of  the  necessity  for  these  laws.  Under  such  authority  from 
the  State  a  city  may  regulate  the  size,  plans,  ventilation,  and  plumbing  of  the 
habitations  of  its  citizens,  even  to  the  extent  of  making  it  impossible  for  per- 
sons of  limited  means  to  find  shelter  within  its  boundaries.  Tenement-house 
regulations  may  })roduce  this  result,  and  it  is  a  question  of  expediency  as  to 
where  the  line  sliall  be  drawn.  A  city  cannot  be  kept  healthy  unless  a 
reasonable  standard  of  what  is  fit  for  human  beings  to  live  in  is  fixed  and 
maintained  ;  there  must  be  a  limit  to  the  lowest  kind  of  habitation  which  it  is 
permissible  to  furnish,  just  as  there  is  for  unwholesome  food.  In  each  case 
the  libertv  of  the  seller  and  the  buver  is  to  a  certain  extent  interfered  with, 
but  neither  has  any  legal  claim  on  the  community  for  compensation  on  that 
account. 

The  question  as  to  whether  a  State,  or  a  city  acting  by  authority  of  the 
State,  can  by  statute  compel  physicians  to  report  to  the  local  authorities  the 


SANITARY  JURISPRVDEXCE.  45 

names  and  residences  of  all  persons  afflicted  with  contagious  or  infectious 
disease  who  are  their  patients,  under  penalty  and  without  compensation,  has 
been  decided  in  the  affirmative  in  1887,^  by  the  Supreme  Court  of  Errors  of 
the  State  of  Connecticut,  but  the  wisdom  and  justice  of  this  decision  are  very 
questionable,  especially  as  applied  to  States  having  no  regulations  as  to  the 
qualifications  of  persons  permitted  to  practise  as  physicions. 

'  See  the  State  vs.  N.  E.  Wordin,  Twelfth  Annual  Report  Connecticut  Slate  Board  of  Health, 
1890,  p.  249. 


EPHEMERAL  FEVER  AND  SIMPLE  CONTINUED 

FEVER. 


By  WILLIAM  PEPPER. 


Definition,  Synonyms. — Tiiese  terras  are  used  to  describe  forms  of 
febrile  disturbance  which,  so  far  as  can  be  determined,  are  not  due  to  specific 
infection  or  to  any  inflammatory  lesion.  They  are  unattended  with  definite 
lesions  or  with  characteristic  eruptions ;  their  symptoms  are  usually  mild  and 
their  termination  favorable.  When  the  aifection  lasts  only  from  twenty-four 
to  seventy-two  hours,  it  is  called  ephemeral  fever,  while  the  duration  of 
simple  continued  fever  or  febricida  is  more  commonly  from  seven  to  twelve 
days,  though  it  may  not  exceed  four  or  five. 

History. — With  the  older  writers  these  forms  of  fever  occupied  a  promi- 
nent position.  As  diagnosis  has  become  more  accurate  and  our  knowledge  of 
the  variations  in  the  course  of  the  infectious  fevers  more  minute,  many  cases 
which  would  formerly  have  been  regarded  as  ephemera  (ephemeral  fever)  or 
synochus  simplex  (simple  continued  fever)  are  found  to  be  abortive  forms  of 
some  infectious  disease  or  to  be  dependent  on  a  latent  local  lesion.  All  careful 
observers  will,  however,  agree  that,  after  making  full  allowance  for  these 
sources  of  error,  cases  are  met  with  not  infrequently  Avhich  must  still  be 
referred  to  one  or  the  other  of  the  above  headings.  It  must  be  admitted  that 
such  reference  is  always  made  with  the  feeling  that  a  more  refined  diagnosis 
than  is  yet  possible  might  show  in  any  such  case  some  mild  infection  or  some 
obscure  irritation. 

Etiolog-y. — Children  and  adolescents  are  much  more  liable  to  these  feb- 
rile attacks  than  older  persons,  yet  cases  are  met  with  in  adults  or  even 
in  advanced  age.  It  is,  indeed,  a  matter  of  common  observation  that  certain 
individuals,  of  whatever  age,  exhibit  the  phenomena  of  fever  with  extreme 
facility  from  the  operation  of  apparently  trifling  causes.  The  heat-regulating 
mechanism  in  these  subjects  is  so  readily  deranged  that  it  constitutes  a  strong 
susceptibility,  amounting  almost  to  an  idiosyncrasy.  In  such  persons  it  is 
pi'obable  that  areas  of  local  irritation  too  slight  and  too  limited  to  produce 
recognizable  symptoms  of  functional  disturbance  may  suffice  to  cause  a  mild 
fever  of  short  duration. 

It  is  often  suggested,  in  studying  closely  the  symptoms  of  the  more  import- 
ant fevers,  that  this  element  of  individual  susceptibility  plays  its  part  there 

46 


SYJfPTOJfA  TOL  O  G  Y.  47 

also,  and  helps  to  explain  the  wide  variation  in  the  degree  of  pyrexia  induced 
in  diHerent  cases  of  apparently  equal  degree  of  infection. 

Extreme  mental  or  bodily  fatigue,  great  excitement  or  anxiety,  undue 
exposure  to  the  direct  rays  of  the  sun,  may  be  reckoned  among  the  well- 
ascertained  causes  of  ephemeral  and  simple  contiiuicd  fever.  The  most  severe 
results  of  these  causes  are  observed  in  tropical  climates,  and  especially  in  the 
case  of  young  and  robust  persons  who  have  not  yet  become  fully  acclimated. 
Indeed,  it  is  probable  that  some  of  these  cases  are  rather  to  be  regarded  as 
mild  cases  of  insolation  or  thermic  fever.  The  su.scei)tibility  of  the  system 
is  increased  by  such  influences,  the  power  of  the  heat-controlling  centres  is 
lowered,  there  is  notable  increase  in  the  amount  of  the  results  of  tissue-waste 
to  be  disposed  of,  so  that  the  causation  of  pyrexia  even  here  is  more  or  less 
complex. 

Again,  it  is  apparent  that  different  individuals  present  widely  different 
degrees  of  liability  to  derangement  of  the  chemical  processes  concerned  in 
digestion  and  assimilation,  and  that  in  some  subjects  the  development  of 
ptomaines  with  strong  pyrogenic  properties  is  readily  induced.  For  in- 
stance, I  have  observed  several  attacks  of  violent  fever,  of  short  duration, 
but  Avitli  a  temperature  of  from  104°  to  106°,  produced  in  a  man  past  mid- 
dle age  by  the  ingestion  on  each  occasion  of  a  moderate  amount  of  cheese  and 
beer.  It  is  obvious  that  in  all  such  cases  the  existence  of  more  or  less  gas- 
tric irritation  is  to  be  counted  u])on,  and  that  this  is  responsible  for  a  share 
of  the  febrile  disturbance. 

In  some  individuals  the  susceptibility  to  noxious  vapors,  as  sewer-gas  or 
the  emanations  from  putrescent  organic  matter,  is  so  great  that  fever  may  be 
induced  by  exposure  to  their  influence. 

Symptomatology. — The  onset  in  ej)hemeral  fever  is  abrupt  and  is  not  pre- 
ceded by  any  prodromes.  There  is  rarely  a  chill ;  in  nervous  children  a  con- 
vulsion may  occur  at  the  begimiing  of  the  attack.  The  fever  rises  rapidly  to 
101°,  103°,  or  even  105°  F.  I  have  seen  it  reach  106°  within  eighteen  hours 
after  the  onset.  It  is  attended  with  headache  and  dulness  or  marked  hebetude. 
Restlessness,  mild  delirium,  and  irregular  muscular  twitching  may  occur, 
especially  in  children.  The  face  is  flushed,  the  skin  hot  and  dry,  the  i)ulse 
rapid,  full,  and  tense.  The  tongue  is  coated  white ;  the  tonsils  are  occasionally 
reddened  and  somewhat  swollen.  Appetite  is  lost ;  nausea  and  vomiting  may 
occur.  The  bowels  are  costive,  and  tyi)ical  febrile  urine  is  secreted  in  scant 
amount.  There  is  no  characteristic  cru])tion,  but  in  children  with  delicate 
skin  and  vigorous  circulation  there  may  be  a  marked  erythematous  flushing 
of  the  surface.  Herpes  often  a])])ears  on  the  lips.  At  the  close  (»f  twenty- 
four,  forty-eight,  or  seventy-two  hours  the  fever  terminates  by  rai)id  subsi- 
dence or  bv  abrupt  crisis.  Vm^  persj)iration,  dinrrluea,  or  eo|)i<»us  urination 
marks  the  defervescence.  The  svuijitoms  clear  away  prom|)(iy,  aiwl  conva- 
lescence is  rapidly  completed.  In  many  instances  the  whole  ])roeess  is  much 
milder  than  as  above  skelclied. 

Simple  continued  fever  may  be  less  abrupt  in  its  onset,  and  for  (he  first  two 


48        EPHEMERAL  FEVER  AND  SIMPLE  CONTINUED  FEVER. 

or  three  days  the  fever  may  rise  gradually  till  it  reaches  102.5°  or  103.5°.  The 
ascent  is,  however,  more  rapid  as  a  ride  than  in  typhoid.  The  nervous  symp- 
toms are  mild.  Sleep  is  disturbed  and  slight  nocturnal  wandering  may  occur. 
Headache  and  some  degree  of  dulness  are  present.  Catarrhal  symptoms  are 
not  marked.  Dulness  of  hearing  is  infrequent.  Occasional  cough  and  a  few 
bronchial  rales  may  be  present.  The  pulse- respiration  ratio  is  fairly  preserved, 
and  may  be  represented  by  96  :  24  :  103°  in  ordinary  cases.  The  heart's  action 
retains  its  tone,  and  the  pulse,  at  first  full  and  bounding,  merely  grows  softer, 
but  rarely  feeble  or  rapid.  The  tongue  remains  moist,  though  heavily  coated. 
Appetite  is  much  impaired,  and  thirst  is  rarely  marked.  Vomiting  rarely 
occurs  unless  provoked.  The  abdomen  is  but  slightly  if  at  all  meteoric;  the 
bowels  are  commonly  torpid,  though  if  intestinal  catarrh  coexists  a  tendency 
to  looseness  may  be  present.  The  spleen  is  but  little  if  any  enlarged.  The 
urine  is  moderately  febrile  in  character,  is  often  passed  quite  freely,  and  con- 
tains a  trace  of  albumin  only  in  a  small  proportion  of  cases.  Slight  epis- 
taxis  occasionally  occurs.  There  is  no  characteristic  eruption.  Sudamina  are 
common,  as  is  also  an  eruption  of  herpes  on  the  lips  and  face.  Pale  bluish 
or  slate-colored  spots,  several  lines  in  diameter,  not  elevated  above  the  surface 
and  not  modified  by  pressure,  are  sometimes  seen,  but  have  no  special  diagnos- 
tic value,  as  they  may  be  observed  in  other  diseases. 

The  fever  usually  continues  ten  or  twelve  days.  It  may,  however,  end 
much  sooner,  as  in  six  or  even  four  days,  or  much  more  rarely  it  may  be 
protracted  to  fourteen  or  fifteen  days.  The  daily  maximum  is  usuallv  in 
the  evening ;  an  inverted  type  Avith  morning  maxima  is,  however,  not  rare, 
especially  in  children.  Hyperpyrexia  is  very  uncommon,  and  the  averao-e 
maxima  are  102.5°  to  103.5°.  The  daily  range  of  temperature  may  be  so 
marked — 2.5°  or  even  3° — as  to  make  the  case  resemble  a  malarial  remit- 
tent. Some  cases  of  so-called  infantile  remittent  fever  are  undoubtedly  of 
simple  continued  type,  while  others  are  abortive  typhoid.  Defervescence  is 
not  so  abrupt  as  in  ephemeral  fever,  and  yet  is  commonly  more  rapid  than 
in  typhoid.  The  temperature  often  becomes  subnormal  for  a  day  or  two, 
with  abnormally  slow  pulse.  Critical  discharges  as  of  sweat,  or  from  the 
bowels,  or  of  urine  heavily  loaded  with  urates,  or  in  the  form  of  epis- 
taxis,  or  of  haemorrhage  from  the  bowels  or  the  uterus,  may  attend  the 
defervescence. 

More  severe  grades  of  simple  continued  fever  are  sometimes  met  with  when 
the  range  of  temperature  is  much  higher  and  the  nervous  symptoms  are  more 
pronounced.  This  type  of  the  disease  is  especially  apt  to  occur  in  the  tropics, 
where  it  has  long  been  known  under  the  name  of  ardent  continued  fever. 
Even  in  the  more  severe  type,  as  met  with  here,  death  is  of  rare  occurrence, 
but  the  violent  cases  observed  by  Murchison  and  others  in  India,  and  espe- 
cially among  robust  young  European  new-comers,  not  infrequently  ran  into  a 
state  of  profound  stupor  with  heart  failure,  and  terminated  in  death  by  the 
sixth  or  ei<i;hth  dav  or  even  earlier. 

Diagnosis. — Ephemeral  fever  in  children  often  simulates  scarlatina  in  the 


niA  GXOSIS.  49 

abruptness  of  its  ouset  and  the  sudden  development  of  high  fever,  with  vomit- 
ing and  restlessness.  But,  although  tiiere  is  a  vivid  febrile  flush,  the  charac- 
teristic eruption  of  scarlatina  is  wanting,  and  there  is  no  sore  throat  or  swelling 
of  the  glands  at  the  angles  of  the  lower  jaw.  Great  anxiety  is,  however,  often 
caused  for  twelve  or  twenty-four  hours. 

Both  in  ephemeral  and  simple  continued  fever  it  is  necessary  to  exclude 
acute  gastric  or  gastro-intestinal  catarrh.  A  certain  amount  of  functional  dis- 
turbance, anorexia,  nausea,  even  vomiting  and  diarrluxni,  may  attend  these 
types  of  fever  ;  but  a  careful  consideration  of  the  circumstances  preceding  the 
attack,  of  the  proportion  between  the  degree  of  fever  and  of  gastro-intestinal 
disturbance,  and  of  the  effect  of  remedies  to  allay  the  mucous  irritation,  will 
lead  to  a  correct  diagnosis. 

It  is  of  course  necessary,  before  pronouncing  a  diagnosis  of  ephemeral  or 
simple  continued  fever,  to  exclude  by  careful  examination  the  existence  of  any 
local  inflammatory  affections,  as  of  the  kidney,  lungs,  pleurfp,  or  heart.  The 
fact  that  in  children  especially,  but  occasionally  also  in  older  subjects,  rheu- 
matic fever  may  occur  without  arthritis,  and  that  in  this  form  of  the  disease 
endocarditis  is  very  likely  to  be  jiresent,  warns  us  that  such  cases  may  be  mis- 
taken readily  for  ephemeral  or  simple  continued  fever.  A  child  of  ten  years 
who  seems  flushed  and  drooping,  with  slight  hoarseness  and  occasional  cough, 
but  still  about  the  room  and  without  definite  complaint,  is  found  to  have  a 
temperature  of  104.5°  F.  and  an  acute  mitral  murmur.  Prompt  and  energetic 
treatment  is  followed  by  abrupt  fall  of  temperature  on  the  third  day,  but  the 
endocarditis  requires  a  month  before  complete  cure  is  effected.  Similar  cases 
are  not  rare,  and  their  true  nature  is  often  overlooked.  The  affection  is 
regarded  as  an  ephemeral  fever,  and  only  long  afterward  does  the  detection 
of  organic  heart  disease  show  that  it  has  been  an  acute  rheumatic  fever  Mith 
latent  endocarditis. 

Simple  continued  fever  must  be  carefully  distinguished  from  malarial 
remittent  fever  and  from  typhoid.  When  the  time  and  place  of  the  attack 
and  the  character  of  the  fever  suggest  a  malarial  nature,  the  absence  of 
marked  enlargement  of  the  spleen,  the  ftii lure  of  full  doses  of  quinine  to 
produce  decided  effect  on  the  course  of  the  case,  and  the  failure  to  detect  the 
malarial  organisms  in  the  blood,  will  dispel  the  suspicion.  Herpes  is  about 
equally  frequent  in  the  two  affections. 

In  the  article  on  Typhoid  F'evkr  attention  is  urged  lo  the  cases  of  an 
abortive  type  which  may  rescnd)lc  greatly  sinq)le  continued  fever.  In 
ordinary  cases  also  it  may  l)e  for  several  days  dinieuJI  m-  impossible  \n  decide 
which  disease  exists.  The  ])rodromes  are  less  marked  in  simple  coiiliiuied 
fever;  the  temperature  is  apt  to  rise  more  rapidly  ;  the  s|>Ieen  does  not  eidarge 
so  decidedly;  the  Ehrlich  renetion  is  likely  to  be  absent  ;  episfaxis  and  loose- 
ness of  the  bowels  are  more  rare;  aii'l  no  cliaracferisfie  ernjilioii  makes  ils 
appearance,  while,  on  the  other  hand,  herpes  is  of  far  more  fn^pient 
occurrence.  It  must  be  remend)ere<l.  however,  (hat  in  some  cases  of  ty|)hoid 
the  eruption  is  postponed  or  even  ab.Miit,  and  that  the  abdominal  symptoms 

Vol.  I.— 4 


50        EPHEMERAL  FEVER  AND  SIMPLE  CONTINUED  FEVER. 

may  be  but  slight;  so  that  the  ditfereiitial  diagnosis  may  remain  in  doubt 
until  the  somewhat  abrupt  defervescence  at  the  tenth  or  twelfth  day  leaves  it 
still  uncertain  if  the  case  has  been  one  of  mild  irregular  typhoid  or  of  simple 
continued  fever. 

Prog-nosis. — The  prognosis  in  these  forms  of  fever  is  uniformly  favorable 
in  tiiis  countrv.  It  is  only  when  a  case  of  unusual  severity  occurs  in  a 
very  frail  subject,  and  especially  if  in  infancy  or  old  age,  that  a  fatal  result 
need  be  feared.  In  the  tropics,  where  the  affection  assumes  a  much  more 
violent  type,  death  not  rarely  occurs,  or  if  life  is  spared  convalescence  may 
be  protracted,  and  serious  sequelae,  chiefly  affecting  the  nervous  system,  may 
linger. 

There  are  no  characteristic  anatomical  lesions.  When  death  occurs,  the 
only  changes  are  those  of  intense  internal  congestion  with  serous  effusions. 

Treatment. — Absolute  rest  in  bed  must  be  insisted  upon.  This  is  essen- 
tial, not  only  for  the  more  speedy  cure  of  simple  fever,  but  to  avoid  all  chance 
of  damage  in  case  an  obscure  local  inflammatory  lesion  or  an  irregular  typhoid 
fever  is  developing.  The  diet  is  to  be  carefully  restricted  and  exclusively 
liquid.  Water  may  be  allowed  freely  as  called  for  by  thirst,  unless  marked 
.  irritability  of  the  stomach  exists.  In  that  event  small  pieces  of  ice  may  be 
swallowed ;  or  small  amounts  of  carbonated  water,  of  equal  parts  of  milk 
and  lime-water,  of  liquid  peptonoids,  may  be  relied  upon,  A  short  course 
of  fractional  doses  of  calomel,  gr.  J^,  every  two  hours  for  one  or  two  days, 
followed  by  a  mild  saline  if  no  loose  movement  occur,  or  repeated  small  doses 
of  liquid  effervescing  citrate  of  magnesium,  may  be  given  with  advantage  at 
the  outset.  Later  it  is  usually  preferable  to  overcome  constipation,  if  it 
should  exist,  by  laxative  enemas  or  suppositories. 

In  cases  where  the  symptoms  suggest  the  existence  of  malaria,  and  ])end- 
irig  tlie  examination  of  the  blood,  full  antiporiodic  doses  of  quinine  should 
be  given.  But  except  for  this  purpose  it  is  not  indicated  in  these  simple 
fevers  unless  asthenic  sym})toms  supervene.  Small  and  frequently  repeated 
doses  of  aconite,  alone  or  with  spirit  of  nitrous  ether,  effervescing  or  neutral 
mixture,  or  solution  of  acetate  of  ammonium,  may  suffice  to  moderate  the  fever. 
Spongings  of  the  surface  with  cool  water,  or  more  vigorous  hydrotherapy,  as 
fully  described  in  the  article  on  Typhoid  Fever,  should  be  used  according 
to  tlie  grade  of  the  pyrexia.  In  the  ardent  continued  fever  of  the  tropics  the 
early  and  systematic  use  of  cold  baths  must  evidently  be  insisted  upon,  and 
cardiac  sedatives  may  be  required  in  addition.  Headache  and  restlessness  may 
be  relieved  by  cold  applications  to  the  head,  by  a  hot  mustard  foot-bath  or  a 
sinapism  to  the  nucha,  and,  if  necessary,  by  proper  doses  of  chloral  and  potas- 
sium bromide.  A  few  doses  of  antipyrine,  gr.  5,  or  of  phenacetin,  gr.  3,  may 
exert  a  happy  febrifuge  and  tranquillizing  effect. 

When  the  early  symptoms  suggest  the  possibility  of  typhoid  fever  or  the 
presence  of  gastro-intestinal  catarrh,  the  use  of  silver  nitrate  or  some  other 
of  the  remedies  recommended  for  their  surface  action  or  antiseptic  properties 
(see  Typhoid  Fever),  should  be  promptly  instituted,  and  laxatives  should 


TREA  TMKXr.  51 

be  avoided.     Stimulants  are  rarely  required  save  in  debilitated  subjects  or  in 
cases  of  specially  adynamic  tvpe. 

Convalescence  is  usually  prompt  and  uncomplicated  :  a  mild  tonic  may  be 
given  with  advantage,  and  careful  attention  to  personal  hygiene  should  be 
insisted  on. 


TYPHOID  FEVER. 

By  WILLIAM  PEPPER. 


Definition. — Typhoid  fever  is  a  specific,  infectious  febrile  disorder,  sporadic 
or  epidemic,  often  communicated  by  the  contagium  from  the  stools,  character- 
ized by  lesions  chiefly  of  the  intestinal  and  mesenteric  glands  and  the  spleen, 
with  the  constant  presence  in  them  of  the  bacillus  of  Eberth.  The  disease  is 
marked  clinically  by  a  variable  febrile  course  which  lasts  three  or  four  weeks, 
a  rose-colored  macular  eruption,  and  cerebral,  pulmonary,  and  abdominal 
symptoms. 

The  general  tendency  is  to  restoration  to  health  after  slow  convalescence, 
but  relapses  are  not  infrequent ;  there  are  numerous  complications  and  sequelae, 
and  death  may  occur  from  various  causes. 

Synonyms. — Probably  a  hundred  names  have  been  applied  to  this  dis- 
ease both  before  and  since  the  establishment  of  its  essential  difference  from 
typhus  and  other  fevers.  No  more  descriptive  term  has  been  used  than  that 
given  it  by  Huxham,  "  slow  nervous  fever,"  but  this  has  become  obsolete. 
The  title  "  typhus  abdominalis,"  so  generally  employed  by  German  writers, 
is  objectionable,  as  implying  a  relationship  with  typhus  fever  (called  "  typhus 
exanthematicus "  by  way  of  contradistinction)  which  the  accurate  observa- 
tion of  recent  years  has  completely  disproved.  "Enteric  fever"  is  likewise 
objectionable,  because  it  implies  that  the  intestinal  lesion  is  the  basis  of  the 
disease,  instead  of  only  one  of  its  localizations.  In  spite  of  all  objections  to 
the  name  "  typhoid  fever,"  on  account  of  its  vagueness  and  of  its  seemingly 
indicating  a  resemblance  to  typhus  fever,  this  term,  given  to  it  by  Louis  in 
1829,  seems  the  most  appropriate  one,  and  has  passed  into  such  general  use 
that  it  is  desirable  that  it  should  be  adopted  uniformly. 

History. — It  has  been  claimed  by  Murchison  and  other  writers  that  typhoid 
fever  was  known  to  Hippocrates,  and  that  Galen  described  it  under  the  title 
of  "  hemitritceus."     Nothing  definite,  however,  is  heard  of  it  before  the  seven- 
teenth century,  when  Spigelius  seems  to  have  encountered  the  affection,  and  to     ( 
have  observed  in  several  post-mortem  examinations  the  characteristic  intestinal 
lesions.     Bartholin,  Willis,  Panarolus,  Baglivi,  Hoffman,  and  Sydenham  also     J 
appear  to  have  been  acquainted  with  typhoid  fever.     In  the  next  century  are     1 
to  be  noted  the  writings  of  Huxham,  Gilchrist,  Manningham,  Lancisci,  Mor- 
gagni,  and  many  others,  which  (;learly  describe  either  the  symptoms  or  lesions 
now  known  to  be  characteristic  of  the  disease.     There  was,  however,  at  that 
time  no  recognition  of  it  as  a  distinct  entity  or  as  other  than  a  mere  variety       ' 

52 


ETIOLOGY.  53 

of  continued  fever.  Even  the  close  association  between  the  characteristic 
symptoms  and  the  intestinal  lesions  does  not  apj)ear  to  have  been  pointed  out 
by  any  one  before  Bretonneau,  who  began  his  observations  in  1818.  Some 
years  later  Louis  added  greatly  to  a  proper  understanding  of  the  atleetion,  but 
even  yet  no  one  had  determined  sharply  the  points  of  distinction  between 
typhoid  and  typhus  fevers. 

To  Gerhard  and  Pennock  of  Philadelphia,  writing  in  1837,  we  are  indebted 
for  a  thorough  establishment  of  the  separate  existence  of  typhoid  fever  and  for 
clearly  distinguishing  between  the  two  affections.  As  a  result,  the  individ- 
uality and  true  nature  of  typhoid  fever  were  appreciated  in  America  sooner 
than  in  either  France  or  England.  In  Germany,  it  is  true,  Ilildenbrand  in 
1810  showed  that  there  was  a  difference  between  this  disease  and  ty})hus,  but 
regarded  them  as  varieties  simply,  without  establishing  their  independence, 
and  for  years  after  him  German  writers  shared  this  view.  Not  until  1849 
did  Jenner  definitely  demonstrate  in  England  their  non-identity,  though  Stew- 
art in  Scotland  wrote  of  it  in  1840,  and  the  French  observers  were  beginning 
to  grasp  the  fact  at  about  the  same  time. 

Since  1850  the  facts  in  the  case  have  been  fully  recognized  the  world  over, 
and  our  exact  knowledge  has  been  increased  by  numerous  valuable  contribu- 
tions from  various  countries. 

Etiology. — The  study  of  the  causation  of  typhoid  fever  is  of  much  practical 
and  scientific  importance.  There  are  certain  ])redisposing  causes  which  exert 
a  powerful  influence.  It  is  one  of  the  most  widely  distributed  of  infectious 
diseases,  and  is,  in  fact,  ubiquitous.  Although  it  may  occur  in  all  climates,  it 
is  especially  prevalent  in  th€  temperate  zone;  indeed,  it  may  be  stated  to  be 
constantly  present  there  in  greater  or  less  degree.  Yet  it  cannot  be  said  that 
geographical  locality  of  itself  exercises  any  influence  upon  the  frequency  of 
its  occurrence.  The  disease  is  certainly  not  so  unusual  in  the  tropics  as  was 
formerly  supposed,  and  it  is  quite  common  in  Iceland,  Norway,  Sweden,  and 
Finland.  The  great  vitality  which  its  specific  i)oison  possesses,  and  the  manner 
in  which  this  is  diffused  by  rinining  water,  explain  in  large  part  the  extraordi- 
narily wide  dissemination  of  the  affection. 

Season  exerts  a  marked  influence  upon  the  frequency  of  the  occurrence  of 
typhoid  fever.  Although  met  with  in  winter  and  si)ring,  it  is  especially  fre- 
quent throughout  the  late  summer  and  autumn  months.  According  io  Murchi- 
son,  out  of  5988  cases  seen  in  the  London  Fever  Hosjiital  during  twenty-three 
years,  2461  occurred  in  autumn,  1400  in  summer,  1278  in  winter,  and  759  in 
spring.  Bartlett  shows  that  of  645  cases  admitted  to  the  Lowell  Hospital 
during  a  period  of  eight  years,  250  occurred  in  autumn,  163  in  summer,  l.'U) 
in  winter,  and  102  in  spring;  98  cases  being  reported  in  ()ct(.ber  alone,  92  in 
September,  and  86  in  August,  while  48  was  the  greatest  total  ninni)er  in  any 
one  of  the  other  months  of  the  year.  According  to  Osier,  over  50  per  cent. 
of  the  1889  cases  in  the  Montreal  General  Hospital  and  ..I"  tl.<-  i:'.81  cases  in 
the  Toronto  General  Hospital  were  admitted  in  llu"  autmnn  months.  Elal)or- 
ate  statistical  tables  of  epidemics  in  various  parts  of  the  world,  prepare.!   by 


54  TYPHOID    FEVER. 

Hirsch,  prove  the  same  tendency  to  the  occurrence  of  typhoid  fever  in  the  late 
summer  and  the  autumn.  In  consequence  of  this  prevalence  in  the  fall  the 
disease  early  received  in  many  places  the  name  of  "  autumnal  fever." 

Typhoid  fever  is  apt  to  prevail  after  hot  and  dry  summers.  Pettenkofer 
and  Buhl  showed  that  the  disease  was  more  common  when  the  ground- water 
was  low,  which  then  allowed  the  germs  to  develop  rapidly  in  the  soil  and 
filter  through  into  surface  wells.  The  explanation  of  the  method  of  the  action 
of  low  water-level,  as  given  by  Buchanan  and  Liebermeister,  is  that  the  lower 
the  water  is,  the  greater  amount  of  solid  matter  must  be  suspended  in  it. 
Should  there,  then,  be  germs  in  the  soil,  the  water  will  contain  them  in 
larger  proportion,  and  be  to  that  degree  more  poisonous.  It  is  probable 
also  that  when  the  hot,  dry  seasons  break  up  and  are  followed  by  damp 
changeable  weather,  the  resisting  power  of  the  community  is  lowered,  and, 
further,  that  catarrhal  conditions,  which  favor  the  entrance  of  the  poison 
from  the  intestine  into  the  general  system,   are  especially  liable  to  occur. 

It  must  be  clearly  recognized,  however,  that  the  disease  does  not  always 
have  any  connection  with  dry  weather  and  a  low  water-level,  and  that  epi- 
demics often  occur  without  reference  to  the  state  of  the  ground- water.  This 
is  indeed  but  what  would  inevitably  result  from  the  varied  manner  in  which 
contamination  of  water-  and  milk-supply  may  occur. 

Baumgarten  suggests  that  the  dust  of  dry  seasons  may  disseminate  the 
germs ;  and  the  suggestion  adds  to  the  probability  that  in  some  cases  the 
bacilli  may  enter  with  the  inspired  air. 

The  configuration  of  the  ground  and  the  elevation  above  the  sea  are 
apparently  entirely  without  influence  in  the  production  of  typhoid  fever. 

There  is  no  reason  to  believe  that  sex  exerts  any  distinct  influence.  How- 
ever, as  lads  and  young  men  are  most  apt  to  congregate  in  cities,  where  the 
cause  of  typhoid  fever  is  most  constantly  and  powerfully  present,  they 
naturally  furnish  a  larger  proportion  of  the  cases  which  form  the  basis  for 
statistics. 

The  disease  occurs  at  all  periods  of  life,  but  particularly  between  the  ages 
of  fifteen  and  twenty-five  years,  becoming  progressively  less  frequent  after  the 
age  of  thirty-five.  This  is  probably  due,  in  large  measure,  to  the  fact  that  those 
who  are  especially  susceptible  to  the  poison  have  already  suffered  from  the  dis- 
ease at  an  earlier  age,  or  perhaps,  with  even  more  probability,  that  individuals 
of  riper  years  have  already  become  immune  through  constant  exposure  to  the 
germs.  Typhoid  fever  is  not  infrequent  between  the  ages  of  thirty-five  and 
fifty  years,  and  is  occasionally  met  with  even  up  to  extreme  old  age.  It  is  far 
more  general  in  early  life  than  is  usually  recognized.  Murchison  reports  its 
occurrence  in  an  infant  six  months  of  age,  and  Charcellay  reports  two  cases  in 
infants  but  a  few  days  old,  while  several  observers  have  discovered  evidences 
of  the  disease  in  \he  foetus.  I  have  observed  several  cases  during:  the  first 
year  of  life,  and  have  seen  patients  recover  from  well-marked  attacks  at 
the  age  of  seventy-two  and  even  seventy-five  years.  Hamernyk  records  a 
case  in  a  patient  aged  ninety  years. 


ETIOLOGY.  55 

It  is  important  to  note  the  difference  in  individual  susceptibility  to  the 
poison  of  the  disease.  It  is  altogether  probable  .that  few  inhabitants  of  large 
cities  have  not  had,  more  or  less  frecpiently,  some  portion  of  the  poison  pass 
through  their  digestive  tract.  It  is  a  matter  of  common  observation  that 
young  men  and  women  who  have  recently  moved  into  cities,  and  who  are 
subjected  to  the  influences  of  change  of  residence,  of  habits,  and  of  diet,  are 
specially  prone  to  the  affection.  Louis  found  that  of  129  cases,  73  had  not 
resided  in  Paris  over  ten  months,  and  102  not  over  twenty  months.  The 
same  influence  of  recent  residence  has  been  observed  by  Murchison  and 
others.  It  has  also  been  noticed  that  those  who  are  apparently  not  susceptible 
to  the  disease  may  lose  this  immimity  by  changing  their  residence,  and  conse- 
quently may  be  attacked  by  it  on  retiu'ning  to  the  house  or  locality  previously 
occupied,  and  in  which  they  had  formerly  been  constantly  exposed  without 
danger.  Then,  too,  I  am  familiar  with  instances  which  indicate  that  certain 
families  may  exhibit  a  high  degree  of  susceptibility,  or  the  reverse,  in  suc- 
cessive generations. 

A  point  which  deserves  careful  consideration  is  the  probability  that  the 
])resence  or  absence  of  a  catarrhal  state  of  the  intestinal  mucous  membrane  at 
the  time  of  the  admission  of  the  poison  to  the  bowel  may  play  an  important 
part  in  determining  the  occurrence  or  non-occurrence  of  infection  by  the  germ. 
In  this  connection  it  is  interesting  to  note  the  frequency  with  which  catarrh  of 
the  tonsils  or  pharynx  precedes  diphtheritic  infection,  or  a  slight  fissure  or 
abrasion  of  the  skin  an  attack  of  facial  erysipelas.  I  have  seen  more  than 
one  instance  in  which  a  patient,  confined  to  bed  with  what  could  only  be 
rcirarded  as  a  simple,  non-specific  gastro-intestinal  catarrh,  has  apparently 
received  the  infection  of  typhoid  fever  from  contaminated  water  or  milk,  and 
developed  the  symptoms  of  a  well-marked  attack  of  the  disease.  It  is  also 
possible  that  some  of  the  relapses  which  are  so  frequent  in  this  disease  are 
due  to  the  admission  of  small  portions  of  fresh  poison,  which,  in  the  sus- 
ceptible catarrhal  state  of  the  mucous  membrane  of  the  bowel,  can  penetrate 
the  epithelial   lining  and  reach  the  lympiioid  tissue  with  especial  ease. 

Apart  from  the  predisposing  influence  of  this  intestinal  catarrh,  the  state 
of  the  individual's  health  has  little  if  any  influence  on  the  development  of 
typhoid  fever.  It  is  indeed  possible  that  depressing  influences,  such  as 
overwork,  prolonged  anxiety,  home-sickness,  may  reduce  the  tone  and  resist- 
ing power  of  the  system  and  render  it  more  susceptible  to  the  poison  of  this 
as  of  some  other  infectious  diseases.  On  ihe  other  hand,  overcrowding,  filth, 
destitution,  and  intemperance  seem  to  be  with(»ut  special  predis|)osing  influence. 
The  consideration  of  the  exciting  causes  of  tyi>hoid  fever  is  wholly  con- 
trolled by  the  fiict  that  a  special  micro-organism,  observed  and  described  by 
El)erth  and  bv  Klebs,  and  after  ihcm  by  K..cli,  CJaffky,  Arlhaud,  Pfcill'cr, 
Friedlandcr,  and  many  others,  has  been  sh..wn  to  be  constantly  ass(.ciated 
with  the  disease.  The  organism  is  a  small  bacillus,  of  alxMit  onc-thir.l  llu- 
diameter  of  a  red  blood-corpuscle  in  length,  oiw-lhinl  as  thick  as  long,  rounded 
at  the  extremities,  and  sometimes  exhibiting  at  one  or  both  cuds,  or,  according 


56  TYPHOID    FEVER. 

to  Arthaiid,  in  the  centre,  a  shining  rounded  body,  possibly  a  spore,  but  pos- 
sibly also  only  a  degenerative  alteration  of  the  protoplasm.  It  occurs  singly 
or  in  filaments  composed  of  a  number  of  bacilli  joined  end  to  end.  The 
descriptions  of  it  vary  considerably,  owing  to  the  fact  that  the  bacillus  itself 
varies  with  the  culture  medium.  All  observers,  however,  agree  on  its  motility 
as  a  characteristic  feature.  Loffler  was  able  to  demonstrate  that  this  motion 
was  due  to  the  presence  of  a  vibratile  cilium.  The  bacilli  are  found  chiefly 
in  the  spleen,  intestinal  and  mesenteric  glands,  and  liver.  Pfeiffer  was  the 
first  to  discover  them  in  the  stools.  They  are,  however,  rarely  detected 
before  the  period  of  actual  ulceration,  when  they  become  much  more  numerous. 
According  to  Chantemesse  and  Widal,  they  exist  in  great  numbers  in  the  pas- 
sages from  the  tenth  to  the  sixteenth  or  seventeenth  day,  but  disappear,  as  a 
rule,  after  the  twenty-second  day.  They  have  been  observed  in  the  kidney, 
and  Neumann  and  Karlinski  found  them  in  the  urine.  They  have  been  dis- 
covered in  the  expectoration  in  certain  cases,  and  also,  though  rarely,  in  the 
blood.  Riitimeyer  reports  their  presence  in  blood  taken  from  the  rose-colored 
S})ots.  They  have  also  been  reported  as  occurring  occasionally  in  many  other 
parts  of  the  body,  as  in  the  meninges  of  the  brain  and  of  the  spinal  cord,  the 
substance  of  the  cord,  the  heart-muscle,  lungs,  and  testicle.  They  have  been 
found,  further,  in  pus  from  an  encapsulated  peritonitic  abscess,  in  periosteal 
abscesses,  in  empyema,  and  in  serous  pleural  effusion. 

Perhaps  in  this  connection  it  can  be  best  recorded  that  Widal  and  Chante- 
messe found  bacilli  in  the  placenta  from  a  woman  who  aborted  at  the  fourth 
month  on  the  twelfth  day  of  an  attack  of  typhoid  fever  ;  Neuhaus  in  the 
liver  and  spleen  of  the  foetus  ;  Eberth  in  the  foetal  blood  from  various  parts 
of  the  body ;  and  P.  Ernst  in  the  spleen  and  the  blood  from  the  heart  in  the 
case  of  a  child  prematurely  born  of  a  mother  with  typhoid  fever,  which  died 
suddenly  on  the  fourth  day  of  life.  The  mother  had  received  an  injury  some 
days  before  labor  which  had  probably  produced  a  lesion  of  the  placenta.  The 
experiments  of  Frilnkel  upon  guinea-pigs  led  him  to  believe  that  the  bacilli 
could  not  be  transmitted  from  mother  to  foetus  unless  there  had  been  an  injury 
to  the  placenta  ;  and  Eberth  holds  much  the  same  view. 

The  bacilli  of  Eberth  will  produce  pure  cultures  on  potato,  gelatin,  agar, 
and  in  blood-serum  and  bouillon.  They  grow  rapidly  in  sterilized  milk,  and 
become  quite  large.  They  have  been  found  to  live  in  milk  for  thirty-five 
days,  and  in  butter  for  twenty-one  days.  In  fact,  as  Heini  has  shown,  there 
is  scarcely  any  article  of  diet  which  does  not  form  an  excellent  culture  medium 
for  this  bacillus. 

Very  few  of  the  cultures  are  characteristic,  that  on  the  potato  being  the 
most  so.  Even  this,  however,  is  so  like  that  of  the  colon  bacillus  that  much 
confusion  has  arisen  and  still  exists,  especially  as  this  bacillus,  like  that  of 
Eberth,  penetrates  at  times  into  different  tissues  of  the  body.  There  is  no 
doubt  that  the  (;olon  bacillus  has  re])eatedly  been  mistaken  by  able  observers 
for  the  typhoid  bacillus.  The  uncertainty  has  indeed  gone  so  far  that  Vaughn 
concludes,  from  an  elaborate  series  of  experiments,  that  the  Eberth  germ  is  not 


ETIOLOGY.  57 

a  specific  Diicro-organism,  but  a  modified  form  of  any  one  of  a  number  of  other 
closely-related  germs.  In  this  opinion,  wiiich  seems  improbable  in  the  light 
of  what  we  know  of  other  infectious  diseases,  he  is  upheld  by  some  other 
investigators. 

It  lias  been  claimed  that  successful  inoculation  experiments  have  been 
made,  but  this  matter  does  not  appear  to  be  positively  determined  as  yet.  The 
typhoid  bacilli  unfortunately  possess  tenacious  vitality.  They  have  been 
known  to  remain  active  and  virulent  in  parts  of  the  organism  for  as  long  as 
fifteen  months  after  the  convalescence  of  the  patient.  Outside  of  the  body  it 
seems  undoubted  that  they  may  retain  their  vitality  for  weeks  in  water,  and 
may  even  increase  in  number,  while  in  illy-drained  soil  they  are  capable  of 
multiplication  and  growth,  and  thus  continue  to  live  indefinitely.  Although 
they  are  killed  by  exposure  for  twenty  minutes  to  moist  heat,  they  are  not 
killed  by  heavy  frost.  Prudden  has  shown  that  they  may  retain  their  vitality 
in  ice  for  months,  and  Seitz  that  they  will  grow  at  a  temperature  of  37.4°  F. 
They  develop  rapidly  in  milk,  without  altering  its  appearance  in  any  res]iect. 
It  would  appear  that  they  will  continue  to  live  in  fseces  for  extraordinarily 
long  periods.  Magnant  reports  a  small  epidemic  of  fourteen  cases  which  he 
could  ascribe  only  to  the  careless  emptying  of  a  privy-well  into  which  the 
stools  of  a  typhoid-fever  ])atient  had  been  emptied  a  year  before.  Utfelmann 
says  that  in  one  instance  under  his  observation  the  bacilli  had  certainly 
remained  alive  and  virulent  for  over  a  year.  He  made  some  interesting 
experiments  bv  adding  pure  cultures  to  faeces  under  different  conditions,  and 
found  the  bacilli  still  living  after  four  months.  Karlinski's  experiments, 
while  indicating  a  shorter  duration  of  life  than  this  for  the  bacilli,  still  prove 
their  great  hold  upon  it.  It  has  been  found,  too,  by  Grancher  and  Deschamps 
that  typhoid  germs,  placed  upon  the  surface  of  frequently  moistened  ground, 
will  penetrate  to  the  depth  of  fifty  centimetres,  and  there  retain  their  life  for 
five  and  a  half  months. 

Just  how  long  the  bacilli  may  live  in  ordinary  water  is  not  positively 
known.  Under  favorable  circumstances  they  may  persist  twenty  to  thirty 
days.  Hochstetter  even  found  them  live  twelve  days  in  a  syphon  of  selt/A'r- 
water.  It  is  certain  that  they  will  live  a  shorter  time  in  running  water  than 
in  cisterns  or  reservoirs. 

Sunlight  i^roves  quite  destructive  to  the  germs.  Janowsky  found  that 
cultures  ceased  to  develop  after  f..ur  to  eight  hours'  exposure  to  light. 

The  bacilli  enter  the  system  by  the  way  of  the  intestinal  mucous  membrane. 
This  is  certainly  true  in  the  vast  majority  of  cases.  That  they  may  occasion- 
ally enter  by  way  of  the  resjjiratory  tract  has  been  asserted,  but  never  proved. 
That  they  may  be  transmitted   by  way  of  the  placenta  from   mother  t..  fo'tus 

has  already  been  stated. 

Astotiie  exact  mode  of  action  oC  the  ha.-illi  alter  th.-ir  admission  to  the 
intestine,  further  investigations  are  nee<led.  They  may  possibly  nndtiply  in  the 
intestinal  contents  under  favorable  circun.stan.-es.  Knt  vnv  piohablv  als..  they 
immediately  penetrate  the  mucous  membrane  an.l  lodge  in  tl,r  lyini.hati*-  tissue 


58  TYPHOID   FEVER. 

of  the  bowel,  as  well  as  in  the  mesenteric  and  other  lymphatic  glands  and  in 
the  spleen  and  liver.  Here  they  grow  at  the  expense  of  the  tissue  and  produce 
necrosis.  During  their  growth  they  develop  certain  toxic  agents,  Brieger 
describing  a  ptomaine  (typhotoxicon),  and  later,  with  Frankel,  a  toxalbumin; 
and  Vaughn  a  ptomaine  which  produces  vomiting,  purging,  and  rise  of  tem- 
perature in  dogs.  It  is  probable  that  the  constitutional  symptoms  of  the  dis- 
ease are  the  result  of  the  action  on  the  system  of  these  or  analogous  toxic 
products. 

Typhoid  fever  is  not  contagious  in  the  ordinary  sense  of  the  terra.  There 
are  no  exhalations  from  the  skin  or  lungs  which  can  impart  the  disease.  The 
infectious  product  is  contained  in  the  discharges  from  the  bowels,  and,  more 
rarely,  in  the  matters  vomited  or  expectorated.  It  must  be  admitted  that  those 
who  handle  these  discharges  or  the  linen  soiled  by  them  may  in  this  way 
acquire  the  disease.  A  very  striking  instance  of  this  has  been  reported  in 
which  the  fever  prevailed  extensively  for  twelve  years  in  one  of  two  German 
artillery  barracks,  but  very  few  cases  occurring  in  the  other.  Finally,  it  was 
found  that  the  lining-s  of  the  trousers  of  almost  all  of  the  soldiers  were  soiled 
with  dried  faecal  matter,  and  that  this  clothing,  thus  previously  contaminated, 
had  been  used  by  the  men  who  were  later  attacked.  Thorough  disinfection 
of  the  clothing  was  now  employed,  and  from  that  time  on  no  more  cases 
developed.  So,  too,  if  the  alvine  discharges  are  placed  where  they  can  dry 
and  the  germs  become  diffused  through  the  air,  it  is  probable  that  they  may 
enter  the  mouth  and  be  swallowed  with  the  saliva.  As  already  stated,  it  has 
been  suggested  that  the  increased  amount  of  dust  in  the  atmosphere  after  hot, 
dry  summers  may  be  an  additional  source  of  occasional  infection.  Undoubt- 
edly, however,  it  is  chiefly  by  the  germs  gaining  entrance  directly  to  the 
flowing  streams  of  water  or  soaking  through  the  ground  and  entering  sources 
of  springs,  and  thus  contaminating  water  used  for  drinking  purposes,  that  the 
disease  sj)reads.  So  many  outbreaks  have  been  studied  critically  and  traced  to 
this  cause  that  it  is  needless  to  do  more  than  refer  to  the  instances  recorded  by 
Murchison  or  by  Hutchinson  (Pepper's  System  of  Medicine,  vol.  i.  p.  250,  et 
seq.).  A  very  interesting  observation  is  that  made  by  Mosny,  that  the  mortality 
from  typhoid  fever  in  Vienna  diminished  from  1.2  per  1000  to  0.11  per  1000 
after  the  introduction  of  spring  water ;  but  that  after  the  water  of  the  Danube 
Was  again  introduced,  though  temporarily,  an  epidemic  broke  out,  which  was 
localized  in  those  parts  of  the  city  supplied  by  this  water.  Very  similar 
observations  have  been  made  on  the  effect  in  Paris  of  temporary  employment 
of  the  river- water  for  drinking  purposes.  As  further  instances  may  be  men- 
tioned the  existence  in  1887  of  ty])hoid  fever  in  towns  along  the  Ohio  River 
for  a  distance  of  over  eight  hundred  miles,  and  the  discovery  by  Rushford  and 
Cameron  of  the  bacilli  in  the  water-supply  ;  as  also  the  epidemics  reported  by 
Brouardel,  Passerat,  Vaughn  and  Novy,  and  Chapin,  in  all  of  which  bacilli 
were  found  in  the  water.  In  the  last-mentioned  both  Prudden  and  Ernst 
found  them  in  the  water-filters  of  the  houses  in  which  the  disease  had 
appeared. 


ETIOLOGY.  59 

One  of  the  most  remarkable  epidemics  which  has  ever  been  reported  is  that 
which  occurred  at  Plymouth,  Pennsylvania,  in  1885,  and  which  was  carefully 
studied  by  L.  H.  Taylor.  In  this  instance  a  mountain-stream  which  supplied 
a  population  of  about  8000  with  ilrinkiuij-water  became  infectetl  by  the 
entrance  of  typhoid  germs  from  a  single  patient  living  close  to  its  edge, 
miles  away  from  the  town  itself.  As  a  result  more  than  lOOO  cases  developed, 
at  the  rate  of  50  to  100  a  day,  and  nearly  100  persons  ilied.  Another,  thougii 
small,  epidemic  has  (piite  recently  been  carefully  studied  by  Seneca  Egbert  of 
the  Laboratory  of  Hygiene,  University  of  Pennsylvania.  In  this  a  small 
manufacturing  village  of  about  sixty  houses  was  severely  infected,  the  infec- 
tion arising  from  a  single  case  brought  ill  to  one  of  the  houses,  and  spread- 
ing by  the  soaking  into  the  sandy,  sloping  soil  of  the  liecal  matter,  and 
the  contamination  in  this  way  of  the  various  wells  from  which  the  drink- 
ing-water was  obtained.  About  50  cases  occurred,  of  whom  (juite  a  number 
died. 

It  is  by  this  contamination  of  the  water-su]>ply  that  many  virulent 
epidemics  in  boarding-schools,  hotels,  and  public  institutions  are  to  be 
explained. 

Infected  milk  is  also  a  frequent  mode  of  conveyance  of  the  ])oison.  The 
milk  may  become  polluted  by  the  water  with  which  it  has  been  diluted  or 
which  has  been  used  to  cleanse  the  cans,  or  the  gern)S  may  be  introduced 
directly  into  the  milk  from  the  hands  of  the  milker,  soiled  with  the  discharges 
of  a  typhoid-fever  patient  whom  he  or  she  is  engaged  in  nursing.  The  latter 
is  evidently  a  less  common  method  of  infection.  Instru(;tive  instances  of 
epidemics  due  to  infected  milk  have  been  reported  by  Murchison,  Cameron, 
and  Ballard.  More  recently  Almquist  reported  an  epidemic  in  Sweden 
where  104  cases  with  11  deaths  occurred  among  jicrsons  all  of  whom  received 
milk  which  was  in  all  probability  contaminated.  Another  milk-epidemic  is 
recorded  by  H.  E.  Smith  as  occurring  at  Waterbury,  Conn.,  and  Littlcjohu 
published  the  account  of  an  epidemic  of  63  cases  traceable  only  to  the  milk  sup- 
plied from  one  dairy.  Numerous  other  instances  of  infection  from  this  source 
})ave  been  recently  reported.  Dr.  L.  II.  Taylor  of  Wilkes- Barrc,  I'm.,  has 
favored  me  with  the  notes,  as  yet  uniMiblislied,  of  such  an  epidemic  occurring 
under  his  observation.  Quite  a  number  of  cases  occurred  in  this  epidemic, 
but  only  in  a  limited  portion  of  the  tr.wn.  A  careful  inv.'sligation  showed 
that  the  disease  could  not  be  traced  to  the  water-supply,  which  was  excej)- 
tionally  pure.  Further  study  revealed  the  fact  that  the  greater  uunibcr  of  the 
patients  had  received  milk  regularly  from  a  certniii  fanii,  that  a  uiimlter  of 
retailers  of  milk  in  the  neighborhood  had  i)rocnreil  milk  from  this  soun-c,  and 
th;il  .1  )H. pillar  druirgist,  who  dispcMised  milk-shakes  to  the  inhabitants  ol  that 
part  of  the  borough,  also  bought  his  milk  from  the  farm.  It  was  discovered 
also  that  a  number  of  persons  living  upon  the  farm  had  been  sick  with  ty|)hoi(l 
fever,  and  it  seemed  beyond  (luestiou  that  this  arose  from  using  the  wal<r  lioni 
a  well  on  the  place  which  examination  showed  was  iiii|»ure.  This  same  water 
was  constantly  em|)loyed  to  wa.sh  and  c<m.1  the  cans;  and  there  c(.uld  hardly  be 


60  TYPHOID    FEVER. 

a  doubt  that  it  was  by  the  milk,  contaminated  in  this  way,  that  the  epidemic 
was  brought  about. 

Upon  the  whole,  the  evidence  does  not  seem  satisfactory  in  support  of  Pet- 
tenkofer's  view  that  the  typhoid  germ,  as  discharged  from  the  patient's  body, 
is  not  in  an  active  state,  but  must  remain  in  the  soil  and  undergo  certain 
changes  before  becoming  capable  of  originating  the  disease.  If  time  is 
required  for  any  such  changes  to  take  place  in  the  germ,  it  is  certainly  very 
short  in  many  instances. 

There  are  certain  reports  of  outbreaks  of  typhoid  fever  which  were  con- 
sidered to  be  due  to  the  use  of  poisoned  meat.  Cayley  has  collected  a  number 
of  instances  of  this  nature.  Careful  study  of  these  cases  seems  to  show,  how- 
ever, that  the  possibility  of  the  poison  having  been  introduced  in  the  usual 
methods  cannot  be  excluded.  It  is  true  also  that  there  are  numbers  of  instances 
recorded  in  which  typhoid  fever  has  arisen  sporadically,  perhaps  in  sparsely- 
settled  regions,  apparently  without  any  conceivable  means  of  infection  of  the 
patient  with  a  typhoid  germ.  Metcalf  reports  such  an  instance  occurring  on 
an  island  in  the  Pacific  Ocean,  where  a  patient  fell  ill  with  typhoid  fever, 
although  there  had  been  no  occurrence  of  the  disease  for  certainly  fifteen 
months,  and  although  no  possibility  of  infection  even  from  this  case  could 
be  discovered.  Numerous  epidemics,  too,  have  occurred  in  which  the  disease 
could  in  no  way  be  traced  to  any  outside  source.  A  conspicuous  instance 
occurred  recently  at  the  military  academy  at  Chester,  Pa.,  where  14  cases  of 
typhoid  fever  developed  among  132  students.  The  cases  I  saw  with  Dr. 
Ulrich,  the  physician  in  charge,  were  of  very  grave  type.  There  were  5 
deaths.  The  epidemic  was  investigated  with  extreme  care  and  thoroughness 
by  Dr.  John  S.  Billings,  who  discoverd  no  source  for  the  infection.  Such 
instances  as  these  have  led  a  number  of  writers  of  note,  with  Murchison 
especially  prominent  among  them,  to  argue  that  cases  may  develop  inde- 
pendently of  pre-existing  typhoid  fever.  In  the  absence  of  more  intimate 
knowledge  of  the  life-history  of  the  Eberth  bacillus  it  seems  unwise  to 
try  to  pronounce  final  judgment  on  this  point.  It  has  been  suggested 
that  this  bacillus,  possibly  in  an  imperfect  state  of  development,  is  widely 
diffused  in  nature  without  reference  to  cases  of  typhoid  fever.  Coming  in 
contact  with  the  results  of  the  decomposition  of  organic  matter,  it  develops 
actively,  and  acquires  a  pathogenic  power  which  enables  it  when  introduced 
to  a  susceptible  system  to  produce  typhoid  fever.  It  is  needless  to  repeat  that 
the  discharges  from  even  a  single  case  of  the  disease  may  contain  so  many 
and  such  virulent  bacilli  as  to  be  able  to  infect  an  extensive  water-course  or 
spread  the  disease  to  hundreds.  In  the  face  of  an  extraordinary  diffusibility 
in  damp  soil,  by  running  water,  and  by  milk  it  is  safer  at  present  to  say 
that,  although  the  origin  of  typhoid  without  direct  connection  with  a  pre- 
existing case  is  possible,  the  evidence  at  hand  does  not  justify  us  in  asserting 
that  it  occurs. 

Morbid  Anatomy. — The  lesions  of  typhoid  fever  are  generallv  divided 
into  two  groups :  those  characteristic  of  the  disease,  and  those  which  may  be 


MORBID    AX  ATOMY.  61 

regarded  as  secondary  changes,  chiefly  due  to  the  effect  upon  the  tissues  of  the 
constitutional  infection  and  the  long-continued  fever. 

I.  The  characteristic  post-mortem  changes  are  seen  in  the  lymphatic 
structures  of  the  intestine,  in  the  mesenteric  and  other  lymphatic  glands, 
and  in  the  spleen. 

.1.  The  alterations  taking  place  in  the  solitary  and  agminated  glands  of  the 
intestine  are  usually  divided  into  four  staires. 

(1)  The  Stage  of  Infiltration. — In  this  tiiere  occurs  a  hyperplasia  of  the 
lymphatic  follicles,  chiefly  of  the  lower  part  of  the  ileum  and  the  cjecum,  but 
sometimes  also  in  the  lower  part  of  the  jejunum,  the  colon,  and  even  the  rec- 
tum. In  some  cases  the  large  intestine  is  the  portion  chiefly  involved.  It 
has  been  claimed  that  the  process  has  been  observed  in  tiie  duodenum  and 
stomach  also.  The  gray-red,  hyperffimic,  and  pearl-like  solitary  follicles, 
enlarged  to  the  size  of  a  pin's  head  or  that  of  a  pea,  project  above  the  surface 
of  the  mucous  membrane.  Their  capillary  blood-vessels  are  greatly  dilated, 
and  finally  become  choked  with  blood-cells.  Later  the  follicles  undergo  a 
great  increase  of  their  cellular  elements  and  grow  firmer,  anaemic,  whitish, 
and  opaque.  The  infiltrating  cells  are  largely  of  the  nature  of  lym])h-cor- 
puscles,  but  some  are  very  large  and  may  contain  ten  or  more  nuclei.  The 
glands  of  Peyer's  patches  also  become  more  prominent,  and  form  flattened  oval 
projections.  They  retain  their  normal  outline,  and  are  separated  sharply  by 
upright  or  overhanging  edges  from  the  surrounding  mucous  membrane.  The 
infiltration  may  extend  beyond  the  glands  to  the  membrane,  the  blood-vessels 
of  which  become  injected,  and  it  may  reach  even  the  muscular  or  serous  layer. 
The  changes  in  Peyer's  glands  are  more  or  less  widely  difl'uscd.  The  lower 
part  of  the  ileum  is  in  all  cases  chiefly  involved,  and  in  mild  cases  a  few 
patches  in  this  region  are  the  sole  seat  of  the  infiltration. 

The  first  sta^e  begins  earlv  in  the  disease.  Murchison  has  detected  it  in 
two  cases  dvinsi:  at  the  close  of  the  first  dav  of  i\w  attack.  It  reaches  its 
height  about  the  middle  of  the  second  week.  In  a  large  number  of  glands 
resolution  now  takes  }>lace,  the  cellular  elements  becoming  fatty  and  granu- 
lar, and  being  absorbed.  The  plaques  may  gradually  become  less  swollen, 
preserving  meanwhile  their  even  surface;  but  as  the  retrogression  takes 
place  more  rapidly  in  tlie  fi)llicles  than  in  the  celhdar  infiltration  of  the 
interfi)llicular  tissue,  the  former  are  very  apt  to  seem  dej>ressed  and  a  retic- 
ular appearance  is  given  to  the  plaques.  It  is  |)('rhaj)s  still  more  probable 
that  this  appearance  is  due  to  a  necrosis  of  the  follicles,  l(>aving  little  i)its. 
The  "shaven-beard"  appearance  also  may  be  |troduced  by  the  deposit  of  pig- 
ment, the  result  of  hffimorrhagie  extravasation,  in  the  depressions  in  the  ful- 
licles.  The  plaques  may  exhibit  this  pigment  even  years  after  recovery  from 
the  disease. 

(2)  Should  resolution  not  occur  the  staf/c  of  /)re/o.s/.s-  develop-.  The  blood- 
vessels become  compressed  by  the  surroiuiding  eellidar  inliltratioii,  and  in  eon- 
sequence  of  lack  of  nourishment  the  follielr'<  die  ;ind  Innn  sloughs.  This 
process  may  occur  in  all  or  in  only  some  of  the  glands  of  the  |)atches,  and 


62  TYPHOID    FEVER. 

may  be  superficial  or  extend  even  to  the  serous  layer  of  the  intestine,  finally 
producing  perforation  of  the  bowel.  The  solitary  glands  undergo  the  same 
change  to  some  extent.  The  process  is  most  marked  at  the  lower  part  of  the 
ileum,  and  in  bad  cases  the  greater  part  of  the  mucous  membrane  in  this 
region  may  be  in  a  sloughing  condition.  The  necrotic  tissue  is  sharply  demar- 
cated from  the  surrounding  parts,  has  a  yellowish,  greenish,  or  brownish  color, 
and  becomes  softer.     Tiie  neighboring  tissue  is  often  decidedly  hypersemic. 

The  second  stage  rarely  begins  before  the  middle  of  the  second  week,  and 
reaches  its  height  toward  the  end  of  this  week. 

(3)  Following  the  necrosis  and  directly  dependent  upon  it  is  the  stage  of 
ulceration.  The  sloughs  loosen  and  gradually  separate,  beginning  at  the  per- 
iphery, and  finally,  at  about  the  end  of  the  third  week,  become  completely 
detached,  leaving  ulcers  of  varying  sizes  and  shapes.  Sometimes  a  whole 
Peyer's  plaque  is  involved,  producing  an  oval  ulcer  of  corresponding  form. 
More  frequently  several  irregularly-shaped  ulcers,  separated  by  bands  of 
mucous  membrane,  may  be  seen  in  one  plaque.  At  the  lower  part  of  the 
ileum  the  ulcers  often  run  together  to  a  great  extent,  and  occupy  almost 
the  entire  circumference  of  this  portion  of  the  bowel.  The  solitary  glands 
likewise  undergo  ulceration,  producing  ulcers  of  a  rounded  form.  The 
walls  of  the  ulcers  are  hypersemic,  swollen,  and  often  overhanging.  The 
floor  varies  in  character  according  to  the  depth  to  which  the  necrosis  has  pen- 
etrated, being  smooth  and  usually  of  a  gray  color  if  the  ulceration  be  super- 
ficial, showing  the  parallel  lines  of  the  muscular  fibres  if  the  mucosa  has 
been  entirely  penetrated,  and  being  smooth  and  transparent  if  the  serous  layer 
be  reached. 

The  ulceration  of  the  solitary  follicles  is  apt  to  be  well  marked  in  tiie 
colon,  and  especially  in  the  caecum,  where  the  ulcers  are  often  very  numerous. 
Eichhorst  has  observed  a  case  in  which  the  only  ulcer  discoverable  anywhere 
was  at  the  tip  of  the  vermiform  appendix.  The  ulceration  may  extend  so 
deeply  that  perfi)rati()n  may  take  place  into  the  peritoneal  cavity.  This  was 
found  to  have  occurred  in  5.7  per  cent,  of  the  2000  autopsies  on  cases  of 
typhoid  fever  made  at  the  Munich  Pathological  Institute,  and  in  21.2  per  cent, 
of  the  64  autopsies  made  at  the  Montreal  General  Hospital. 

(4)  The  stage  of  cicatrization  follows  immediately  upon  that  of  ulceration. 
It  usually  begins  at  about  the  commencement  of  the  fourth  week  and  continues 
for  two  or  more  weeks.  The  walls  of  the  ulcers  become  less  swollen,  and 
attach  themselves  to  the  subjacent  tissue.  Delicate  gray  granulations  cover 
the  floor  of  tlie  ulcers,  and  sometimes  secrete  pus.  Later  the  granulations  are 
replaced  by  connective  tissue.  The  cicatrices  thus  formed  remain  as  smooth 
thin  spots  for  years,  often  exhibiting  pigmentation.  Epithelium  cov'ers  the 
cicatrices,  and  villi  may  even  grow  upon  them,  but  the  true  adenoid  tissue  is 
y)robably  never  replaced. 

Any  one  of  the  stages  described  docs  not  exist  at  one  time  in  the  intestine 
to  the  exclusion  of  other  stages.  Different  glands  may  be  found  illustrating 
two  or  more  stages.     The  neighborhood  of  the  ileo-csecal  valve  is  the  portion 


MORBID    ANATOMY.  0;] 

of  the  bowel  usually  oxhibitiug  the  uiost  advanml  !?tages  of  the  glandular 
lesions.  Again,  the  same  Pever's  patch  may  be  undergoing  cicatrization  in 
one  part,  while  sloughing  is  still  proceeding  or  ulceration  actually  spreading  in 
anotlier  part.  Such  a  condition  of  course  prolongs  the  stage  of  healing  very 
greatly,  and  may  lead  to  perforation  after  convalescence  is  seeminolv  well 
under  way. 

B.  Contemporaneously  witii  the  early  changes  in  the  intestine,  alteration 
takes  place  in  the  mesenteric  glands,  especially  in  those  in  the  vicinity  of  the 
part  of  the  bowel  most  affected,  and  usually,  though  not  always,  in  proportion 
to  the  degree  of  involvement  of  the  intestinal  glands.  Intense  hypertemia  is 
followed  by  swelling  due  to  cellular  infiltration.  The  soft,  swollen  glands,  of 
a  bluish-red  color,  may  vary  from  the  size  of  a  bean  even  to  that  of  a  small 
hen's  c%^.  On  section  the  central  portion  is  often  of  a  lighter  shade  than  the 
perij^hery.  At  about  the  time  of  ulceration  in  the  intestine  resolution  begins 
to  take  place  in  the  mesenteric  glands,  the  histological  process  being  identical 
with  that  seen  in  the  intestinal  follicles.  The  color  then  becomes  paler  and 
yellower,  and  the  swelling  diminishes,  although  the  glands  arc  apt  to  continue 
hyperremic  and  firmer  in  consistence.  Where  the  swelling  has  been  very  great 
spots  of  necrosis  with  softening  occur,  especially  in  the  central  jiortion,  but  the 
puriform  fluid  thus  formed  becomes  absorbed  if  the  process  has  been  limited 
to  a  small  area.  When,  however,  it  is  extensive,  a  large  part  of  a  gland  breaks 
down  and  later  is  transformed  into  a  cheesy  and,  finally,  calcareous  mass. 
Sometimes  a  liquefied  gland  bursts  into  the  peritoneal  cavity. 

Glands  in  other  parts  of  the  body  also  sometimes  become  congested  and 
enlarged.  Particularly  is  this  true  of  the  retroperitoneal  and  bronchial  glands 
and  those  in  the  fissure  of  the  liver.  In  fact,  any  of  the  lymphatic  glands 
mav  occasionallv  undero;o  this  chano-e  to  some  extent.  According  to  I^ieber- 
meister,  the  lymphatic  follicles  at  the  root  of  the  tongue  and  in  the  tonsils  are 
often  affected  in  the  same  way  early  in  the  disease,  but  almost  always  undergo 
resolution. 

C.  The  sj)leen  nearly  always  becomes  enlarged  in  typhoid  fever.  l>irch- 
Hirschfeld,  however,  states  that  this  enlargement  not  uncommonly  fails  to  occur 
in  elderly  persons.  It  may  also  be  absent  when  the  capsule  has  been  thickened 
by  previous  inflammation  and  the  organ  has  heconie  firmly  adherent  to  sur- 
rounding parts.  The  increase  in  size  begins  in  tlic  middle  of  (lie  WxA  week,  and 
reaches  its  height  toward  the  end  of  the  second  week,  the  organ  being  tin  n  Iwo 
or  three  times  its  normal  dimensions.  In  the  fourth  week  <limimiti<»ii  in  \o|iime 
begins,  and  dimensions  nearly  normal  are  icaclied  by  (lie  end  of  the  fifth  week. 
The  dcfrree  of  enlar<rement  varies  much  in  dilTereiil  epidemics,  beitig  ixrealer 
in  the  severer  outbreaks.  The  eidargement  Ijegins  with  liypera-mia,  the  organ 
beiup- tense,  firm,  and  of  a  niiifnfmlv  deep-red  color  when  cut.  The  capillaries 
and  veins  are  dilated,  and  the  sinuses  contain  an  accnnndatinn  dj'  ivd  :nid  of 
white  blood-cells. 

Ciradnally  the  splenic  (issue  grows  softer  an<l  more  -:ramdar,  and  finally 
almost  diffluent  on  section,  and  in  the  second  and  third  weeks  the  Mal|.iglilan 


64  TYPHOID    FEVER. 

bodies,  often  hyperplastic,  appear  as  small  grayish  points.  Blood-pigment  is 
now  very  abundant.  Numerous  large  multinuolear  cells  are  found  in  the 
veins,  and  very  many  splenic  cells  containing  red  blood-corpuscles  or  frag- 
ments of  them  are  present.  Sometimes  as  many  as  twenty  corpuscles  thus 
encysted  may  be  discovered. 

As  the  spleen  grows  smaller  the  capsule  becomes  wrinkled  and  often  cov- 
ered by  grayish  lines.  The  splenic  tissue  becomes  paler,  firmer,  and  often 
browner,  and  the  stroma  is  more  apparent.  Hsemorrliagic  infarcts  are  present 
in  a  proportion  of  cases  variously  estimated  at  from  3.6  to  7  per  cent.  These 
infarcts  may  sometimes  soften  and  rupture.  Rupture  of  the  spleen  may  also 
occur  from  mechanical  iujury.  In  the  2000  Miuiich  cases  already  referred  to 
rupture  took  place  in  5  instances. 

II.  The  lesions  of  the  second  group — i.  e.  those  not  characteristic  of  typhoid 
fever,  but  more  or  less  frequently  seen  after  it — may  be  briefly  discussed. 

Cadaveric  rigidity  occurs  early,  and  is  very  persistent  in  patients  dying  at 
the  height  of  the  disease,  but  it  is  only  slight  when  death  has  taken  place  in 
the  later  stages.  The  degree  of  emaciation  varies,  and  is  not  infrequently  only 
slight  even  after  two  or  three  weeks  of  fever.  Post-mortem  ecchymoses,  gen- 
erally dark  in  color,  but  pale  after  a  protracted  illness,  are  usually  abundant 
in  the  dependent  portions  of  the  body.  The  characteristic  lenticular  spots  are 
never  seen  after  death,  but  sudamina  are  often  visible.  Abscess  or  gangrene 
of  various  parts  of  the  body  may  occasionally  be  found.  The  voluntary 
muscles  are  dry  and  of  a  dark-red  color  in  the  earlier  periods  of  the  disease. 
In  the  third  week  yellowish  spots  and  grayish,  wax-like  streaks  appear  in 
them,  or  an  entire  muscle  may  be  transformed  into  a  shining,  gray,  friable 
mass.  Haemorrhages  and  abscesses  sometimes  occur  in  the  substance  of  the 
muscle,  due  to  the  rupture  of  the  degenerated  fibres.  Rupture  of  the  muscle 
itself  has  been  reported. 

The  peculiar  histological  changes  in  the  muscles — seen  in  other  long-con- 
tinued febrile  conditions  as  well — were  first  pointed  out  by  Zenker,  who 
described  two  forms :  the  one  a  granular  degeneration,  the  other  a  waxy 
variety.  The  first  is  the  more  common,  but  the  two  are  often  associated.  In 
the  granular  degeneration  the  fibres  are  filled  with  granules  which  are  in  part 
albuminous  and  in  part  fatty.  In  the  waxy  form  the  strise  disappear  com- 
})letely,  and  the  muscle  is  transformed  into  a  glistening,  waxy  mass.  The 
muscles  most  apt  to  be  affected  are  the  adductors  of  the  thighs,  the  recti 
abdominis,  the  pectorals,  the  diaphragm,  and  those  of  the  tongue.  These 
degenerative  changes  are  most  marked  in  the  second,  third,  and  fourth 
weeks.  Later  than  this  but  little  evidence  of  the  process  can  be  found. 
The  cause  of  the  degeneration  is  usually  believed  to  be  continued  hyper- 
pyrexia. 

The  muscle  of  the  heart  is  affected  in  a  similar  manner,  though  the  granular 
degeneration  much  exceeds  the  waxy  in  frequency.  The  organ  is  dilated, 
flaccid,  soft,  and  has  a  j)ale-yellowish,  "  faded-leaf  color,"  as  it  is  commonly 
described.     The  degeneration  takes  place  in  patches,  fibres  seriously  diseased, 


MORBID    ANATOMY.  65 

with  the  striae  invisible,  lying  adjacent  to  others  scarcely  at  all  affected.  The 
pa])il]ary  muscles  are  those  oftenest  attacked. 

Myocarditis  is  not  nncomnion,  and  proliferation  of  the  muscle-nuclei  with 
i)ililtration  of  the  connective  tissue  occurs.  Dewevre  found  granular  degen- 
eration of  the  myocardium  in  16  out  of  48  cases.  Endocarditis  and  pericar- 
ditis are  uncommon. 

Thrombi  are  frequent  in  the  chambers  of  the  right  side  of  the  heart,  as  also 
in  the  veins  of  the  body,  particularly  the  femoral,  but  rarely  in  the  cerebral 
sinuses.  The  minute  arteries  of  the  body  exhibit  sometimes  an  endarteritis 
or  a  fatty  degeneration. 

According  to  Ponfick,  the  marrow  of  the  bones  exhibits  at  times  changes 
similar  to  those  of  other  lymphoid  organs.  It  exhii)lts  numerous  large  cells 
which  contain  many  red  blood-corpuscles  and,  later,  pigment.  Periostitis 
sometimes  may  be  seen,  and  Helferich  has  observed  chondritis  of  the  ribs 
in  a  number  of  instances. 

The  pharynx  and  oesophagus  may  sometimes  be  congested  and  exhibit 
ulcers  late  in  the  disease.  A  diphtheritic  deposit  is  occasionally  observed  on 
the  pharynx.  The  stomach  is  in  some  cases  congested.  Softening  is  also 
found  at  times,  but  is  very  probably  a  post-mortem  change.  I'^lccration  some- 
times occurs,  but  is  rare.  The  same  conditions  have  been  observed  in  the 
duodenum.  Tire  jejunum  and  upper  part  of  the  ileum  may  be  congested  or 
may  be  paler  than  normal,  but  rarely  present  any  other  alteration,  except  the 
typhoid  ulceration  sometimes  present.  Great  gaseous  distension  of  these  parts 
is  uncommon.  The  lower  portion  of  the  ileum  is  in  a  catarrhal  condition  and 
is  more  or  less  collapsed.  Its  mucous  membrane  is  reddened,  particularly  near 
the  ulcers,  and  sometimes  exhibits  post-mortem  softening.  The  mucous  mem- 
brane of  the  csecum  and  colon  may  be  of  normal  appearance  or  of  a  ])ale  color, 
or  sometimes  injected  and  softened.  Flatulent  distension  of  the  colon  is  usu- 
ally marked. 

The  liver  shows  evidences  of  parenchymatous  degeneration.  Early  in  the 
affection  it  becomes  hypenemic.  It  is  often  softer  than  normal,  anil  tlic  out- 
lines of  the  lobules  are  indistinct.  Usually  it  is  somewhat  pale,  and  the  cells 
under  the  microscope  are  granular  and  full  of  fat,  with  the  nuclei  indistinctly 
outlined.  In  advanced  cases  the  organ  apj)roaches  the  ap|)carance  seen  in  acute 
yellow  atro])hv.  This  was  seen  in  three  of  the  Munich  ca.ses.  Wagner  has 
described  small  lym])homata,  and  llandford  small  necrotic  areas  in  tin-  organ 
in  persons  dying  during  convalescence,  while  Iloirmami  ibimd  numerous  nud- 
tinucleated  cells  as  well  as  small  mononuelealcd  cells,  a  condition  which  he  re- 
garded as  evidence  of  a  regenerative  process.  Endtolism,  abscess,  and  ein|)hy- 
sema  have  been  reported  as  rare  occurrences.  The  mucous  menibi'anc  of  the 
gall-bladder  may  exhibit  a  catarrhal  or  diphtheritic  inflaiMmation,  or  tdccra- 
tion  of  it  may  occur.  The  bile  is  thin  ami  wa(<'ry  when  the  disease  has 
lasted   three  to  four  weeks. 

Ilollmann  states  that  the  pancrcMs  and  s;illvary  glands  early  become  larger 
and  firmer,  and,  on  section,  browner.     Under  the  microscope  arc  litund  an 

Vol.  I.— 5 


6G  TYPHOID    FEVER, 

* 

increase  in  the  number  of  cells  and  a  granular  degeneration  of  them.  Suppu- 
ration of  the  parotid  gland  occurs  as  one  of  the  complications  of  the  disease. 

Peritonitis  is,  of  course,  found  in  cases  where  death  has  followed  perforation 
of  the  bowel.  Under  these  circumstances  it  is  usually  general,  with  consider- 
able plastic  and  sero-purulent  effusion.  In  rare  instances  the  lesions  of  perito- 
nitis, even  of  the  most  advanced  degree,  may  be  found,  although  no  perfora- 
tion has  occurred,  and  no  starting-point  for  the  inflammation  exists  in  con- 
nection with  any  ulcer  which,  though  not  actually  perforating,  is  so  deep  as 
to  involve  the  serous  membrane.  I  have  seen  this  several  times,  but  only  in 
young  subjects.  It  appears  as  though  it  depended  upon  a  true  localization  of 
the  morbid  process  in  the  peritoneum  in  these  particular  cases,  just  as  at  other 
times  it  may  occur  in  the  pleura.  Recently  I  have  seen  with  Dr.  George  S. 
Gerhard  a  boy,  aged  fifteen  years,  who  in  the  course  of  a  desperately  severe 
attack  of  typhoid  had  sero-plastic  pleurisy  on  the  right  side,  together  with 
peritonitis  which  resulted  in  a  very  large  indurated  mass  occupying  the  right 
hypochondriac  and  median  region,  apparently  comj)osed  of  enlarged  glands, 
inflammatory  exudation,  and  agglutinated  coils  of  intestine.  (See  Fig.  7). 
The  slow  resolution  of  this  large  mass  occupied  several  months,  but  com- 
plete recovery  followed  finally. 

The  kidneys  exhibit  a  parenchymatous  degeneration  similar  to  that  in  the 
liver.  They  are  commonly  slightly  swollen,  rather  pale  and  flabby,  and  some- 
what cloudy  on  section.  There  is  present  a  granular  and  fatty  degeneration 
of  the  epithelial  cells  of  the  tubules,  particularly  of  those  of  the  convoluted 
])ortion.  Infarcts  are  occasionally  seen.  Miliary  lymphomatous  nodules  may 
rarely  be  met  with,  similar  to  those  in  the  liver.  These  may  also  be  sometimes 
found  in  the  peritoneum.  Miliary  abscesses  may  develop  from  the  lymphomata 
in  the  kidney,  and  some  observers  have  found  the  bacilli  in  the  pus  from  these. 
A  diphtheritic  inflammation  has  been  observed  in  the  pelvis  of  the  kidney. 
Osier  noted  this  in  3  of  his  64  autopsies.  The  bladder  likewise  may  exhibit 
a  diphtheritic  inflammation,  and  a  vesical  catarrh  is  not  unusual.  Orchitis  is 
sometimes  seen. 

In  a  considerable  number  of  cases  the  larynx  exhibits  ulceration,  situated 
usually  on  the  posterior  wall  or  on  the  epiglottis,  or  even  involving  the  vocal 
cords.  According  to  Eichhorst,  bacilli  can  be  found  in  the  ulcers.  Diphthe- 
ritic inflammation  of  the  larynx  is  not  unusual.  Qlldema  of  the  glottis  may 
occur  and  may  require  tracheotomy.  This  operation  had  been  found  necessary 
in  20  per  cent,  of  the  Munich  series.  Affections  of  the  trachea  are  rather  rare. 
Catarrhal  inflammation  of  the  bronchi  is  almost  always  present.  Hypostatic 
congestion  with  splenization  of  the  lungs  is  very  common.  Abscess  and  gan- 
grene of  the  lung  are  seen  with  comparative  rarity.  Pulmonary  oedema  is 
common,  infarcts  not  rare,  and  broncho-pneumonia  and  croupous  pneumonia 
are  very  frequent  in  some  epidemics.     Pleurisy  of  any  form  it  not  usual. 

Alterations  of  the  nervous  system  are  unimportant.  Meningitis  is  very 
rare.  A  case  is  reported  by  Kamen  in  which  the  bacilli  of  Eberth  appear  to 
have  been  the   sole  cause.     The  brain-substance  and  membranes  may  early 


II 


CLINICAL    DKSCRIPTIOX.  67 

become  liyperaemic  and  oedematous.  Later  the  convolutions  may  be  somewhat 
atrophic.  Numerous  capillary  iiremorrhagcs  can  be  found  in  the  cortex  in 
some  cases,  but  larger  cerebral  hajinorrhages  are  rare.  Iniridi  could  find  only 
fifteen  reported  cases  in  addition  to  one  observed  by  himself  IMeningeal 
haemorrhages  may  occur.  Meynert  has  described  a  granular  change,  Popotf 
an  infiltration,  and  Hoffmann  a  pigmentation  of  the  ganglion-cells.  The 
peripheral  nerves  may  exhibit  parenchymatous  changes.  Levin  claims  that 
the  ganglia  of  the  trunks  of  the  pneumogastrics  frequently  exhibit  an  inflam- 
matory process,  and  he  believes  that  it  is  on  this  that  such  symptoms  as  laryn- 
gitis, paralysis  of  the  pharynx,  cardiac  irregularity,  and  the  like  dci)end. 

Clinical  Description. — The  conditions  under  which  typhoid  fever  occurs 
usually  render  it  difficult  to  determine  the  length  of  the  period  of  incubation. 
The  general  consensus  of  medical  opinion  places  it  at  about  two  weeks,  but  it  is 
sometimes  certainly  less  than  this.  In  several  instances  under  my  observation, 
where  the  poison  w^as  unusually  concentrated  and  virulent,  I  have  felt  satisfied 
that  it  did  not  exceed  four  or  five  days.  Griesinger  reports  three  cases  in 
which  this  period  seemed  to  last  but  one  day,  but  it  is  exceedingly  doubtful 
whether  these  instances  have  any  real  value,  as  the  diagnosis  was  uncertain. 
More  probably  instances  of  typhoid  fever,  though  not  certainly  so,  were  the 
cases  in  the  outbreak  at  the  school  of  Clapham  to  which  Murchison  refers. 
In  this  local  epidemic  twenty  cases  developed  four  days  after  cxposiu'c  to  the 
infection. 

On  the  other  hand,  the  period  of  incubation  is  said  to  extend  sometimes  to 
three  or  four  weeks,  although  there  are  manifestly  great  difficulties  in  the  way 
of  determining  the  date  at  which  the  last  portion  of  typhoid  ])oison,  which 
may  have  been  the  effective  dose,  was  admitted  to  the  system.  It  is  possible, 
too,  that  in  certain  cases  the  germs  may  for  a  long  time  lie  dormant  in  the 
intestine  or  even  in  the  tissues  until  a  favorable  occasion  arises  for  attacking 
the  system. 

The  stage  of  invasion  may  last  as  long  as  two  weeks,  while  in  other  cases, 
and  especially  if  the  poison  be  concentrated  and  active,  the  disease  will  attain 
marked  severitv  within  two  or  three  davs  from  the  initial  svmptom.  The 
sudden  onset  of  the  attack  without  or  with  such  brief  ])rodromal  .symj>toins  is 
rare.  It  is  more  a])t  to  occur  in  children  than  in  later  life,  excc|)t  in  cases  of 
a  very  malignant  tvpe.  Oftener  the  invasion  is  so  gradual  that  it  is  difficult 
to  determine  the  day  from  which  the  actual  begiiniing  of  the  disease  shoidd 
be  dated. 

The  premonitory  symptoms — sonic  of  which,  at  least,  are  commonly 
exhibited — consist  of  increasing  sense  of  weakness  and  fatigue  on  exertion, 
light  and  disturbed  sleep,  confusion  of  ideas,  fiiilure  oC  :ippe(il<\  occasional 
colicky  pains  in  the  abdomen,  a  tendcMKy  to  slight  looseness  of  (he  bowels, 
nausea,  coated  tongue,  epistaxis,  bronchial  cough,  severe  headache  (which  is 
frequently  occii)Ital),  a  sense  of  weary  aching  in  the  limbs,  and  not  rarely  a 
decided  degree  of  dulness  of  hearing,  especially  toward  the  close  of  the  stage 
of  invasion.     When  these  .symptoms  are  present   in  any  marked  degree  it  is 


68  TYPHOID    FEVER. 

evident  that  they  possess  a  certain  diagnostic  importance,  as  in  no  other  dis- 
ease are  there  sucii  varied  prodromes  extending  over  so  many  days.  I  have 
repeatedly  been  led  to  anticipate  the  approach  of  typhoid  fever  by  the  unusual 
dulness  of  hearing  and  by  the  persistent  occipital  headache  coming  on  after  a 
few  days  of  general  malaise.  The  pulse  may  not  be  disturbed  during  this 
stage,  but  if  the  temperature  be  taken  it  will  usually  be  found  that  there  is 
slight  evening  elevation. 

The  actual  onset  of  the  disease  is  rarely  abrupt,  but  more  frequently  so  in 
children  than  in  adults.  It  may  be  marked  by  some  chilliness  and  evidence 
of  fever,  but  rarely  by  an  outspoken  rigoi*.  The  occurrence  of  decided  fever  is 
usually  the  evidence  of  the  beginning  of  this  stage,  but  as  the  prodromic 
symptoms  very  often  merge  gradually  and  imperceptibly  into  those  of  the 
actually  developed  disease,  it  is  a  common  custom  to  date  the  beginning  of  this 
stage  from  the  time  when  the  increasing  sense  of  weakness  leads  the  patient  to 
take  to  bed.  As  this,  too,  is  a  variable  date,  depending  upon  the  severity  of 
the  attack  and  the  will-power  of  the  patient,  it  often  hajipeus  that  the, case 
must  be  regarded  as  already  in  the  third  or  fourth  day  before  the  confinement 
to  bed  begins  or  before  medical  aid  is  first  sought. 

The  fever  gradually  increases  day  by  day,  usually  presenting  an  evening 
exacerbation,  with  a  remission  in  the  early  morning  hours,  until  by  the  end  of 
the  first  week  it  reaches  103°  or  104°  F.  It  must  be  borne  in  mind,  however, 
that  the  temperature  not  at  all  infrequently  rises  with  miKih  greater  rapidity. 

The  appearance  dui'ing  the  first  week  is  listless  and  apathetic ;  the  hearing 
is  dull  ;  headache  is  often  intense;  and  the  patient  lies,  much  of  the  time,  with 
the  eyes  closed  as  though  in  sleep.  Delirium  is  apt  to  occur,  especially  at 
night.  In  severe  cases  more  marked  nervous  symptoms  present  themselves. 
The  respirations  are  but  moderately  accelerated  ;  the  pulse  is  increased  in  fre- 
quency, but  not  always  in  proportion  to  the  increase  of  temperature.  It  is 
full,  of  low  tension,  and  often  dicrotic.  The  tongue  is  coated,  appetite  is  lost, 
thirst  is  moderate;  the  abdomen  is  moderately  distended,  and  pressure  in  the 
right  iliac  fosssa  will  usually  disclose  some  gurgling  sounds  and  tenderness. 
Constipation  is  present  in  perhaps  the  majority  of  cases  at  first,  but  during  the 
first  week,  if  not  indeed  from  the  outset,  diarrhoea  sets  in,  with  yellowish  and 
liquid  stools.  The  spleen  is  distinctly  enlarged  toward  the  end  of  the  first 
week.  At  about  the  seventh  day  or  later  a  characteristic  eruption  of  rose- 
colored  spots  appears,  usually  first  upon  the  upper  part  of  the  abdomen. 
There  is  occasionally  cough,  sometimes  quite  severe,  and  auscultation  shows  a 
few  scattered  rales.  The  urine  presents  a  febrile  character  and  is  diminished 
in  amount,  es])ecially  if  diarrhoea  be  present,  and  sometimes  contains  a  small 
amount  of  albumin. 

In  the  second  week  the  sym])toras  become  aggravated.  Headache  is  apt  to 
be  replaced  by  an  increased  tendency  to  torpor  and  sonmolence.  Delirium  is 
present,  usually  of  a  mild,  wandering  type,  though  it  may  be  violent.  The  tem- 
perature remains  high  and  presents  a  more  uniform  course,  though  still  marked 
by  daily  remissions.     The  pulse  is  now  more  rapid,  less  full,  and  less  dicrotic. 


CONSIDERATION    OF  SPECIAL   SYMPTOMS.  69 

The  tongue  is  apt  to  lose  its  coating  and  to  beounie  ml  and  more  or  less  dry. 
It  is  protruded  with  difficulty,  and  often  exhibits  tremor.  Tremor  is  also  seen 
in  the  limbs.  The  spleen  increases  in  size.  Kfdes  in  the  lungs  are  more  abun- 
dant.    The  abdomen  grows  more  distended. 

In  the  third  week  the  temperature  becomes  of  a  distinctly  remittent  type, 
the  morning  fall  growing  more  marked,  and  the  height  of  the  evening  eleva- 
tion gradually  lessening.     The  other  symptoms  of  the  ])revious  stage  persist. 

In  some  cases  all  the  symptoms  become  worse  toward  the  end  of  the  second 
week  and  in  the  third  week.  The  stupor  grows  more  extreme ;  the  patient 
can  scarcely  be  roused  at  all ;  the  tongue  is  very  dry  and  is  covered  with  a 
brown  crust ;  the  teeth  are  coated  with  sordes ;  the  pulse  is  rapid  and  feeble  ; 
subsultus  tendinum  is  marked  ;  the  urine  and  faecas  are  often  passed  uncon- 
sciously or  there  may  be  retention  of  urine.  Weakness  is  progressive  and 
great ;  muscular  relaxati<m  is  marked  ;  emaciation  is  often  extreme,  and  there 
is  a  tendency  for  bed-sores  to  develop.  Such  a  condition  is  fitly  termed  the 
typhoid  state.     It  will  be  seen  later  that  it  may  develop  in  other  diseases. 

Tiiese  symptoms  may  persist  until  the  fourth  week  and  the  patient  die,  if, 
indeed,  death  does  not  occur  earlier.  In  cases  which  recover  there  is  a  gradual 
improvement,  commencing  with  the  opening  of  this  week  or  perhaps  soouer. 
The  temperature  is  now  even  more  decidedly  remittent,  and  finally  distinctly 
intermittent,  the  morning  temperature  reaching  normal,  although  the  evening 
temperature  is  still  rather  high.  Tiie  mental  condition  clears  up;  other  ner- 
vous symptoms  improve  ;  the  tongue  becomes  more  moist ;  appetite  returns  ; 
the  distension  of  the  abdomen  disaj)j>ears  ;  diarrhrca  lessens  and  tlie  stools 
become  darker  in  color,  and  constipation  is  finally  apt  to  supervene ;  the 
hvpertrophy  of  the  spleen  diminishes;  the  pulse  improves  in  strength  and 
lessens  in  frequency  ;  the  eruption,  which  had  developed  in  successive  crops, 
ceases  to  appear. 

Convalescence  begins  with  the  entire  disajij^ea ranee  of  fever,  often  marked 
by  a  subnormal  morning  temperature.  It  is  gradual  and  often  tedious,  lasting 
into  the  fifth  and  sixth  week,  and  sometimes  not  beginning  until  then.  Vari- 
ous sequelffi  may  now  occur,  just  as  diilerent  com})lications  may  develop  during 
the  course  of  the  disease.  During  convalescence,  too,  the  patient  is  subject  to 
sudden  temporary  elevations  of  temperature,  produced  by  excitement,  over- 
exertion, or  indiscretions  in  diet.  These  recrudescences  last  a  day  or  two 
only,  and  are  to  be  distinguished  from  true  relapses,  wlildi  <'xhibit  other 
symptoms  of  the  ])rimary   attack  besides   the  mere  febrile  reaction. 

Consideration  of  Special  Symptoms.— Tr'nir/Yr/  CondUion  and  Appear- 
ance.  The  expression  of  the  face  in   tyjilioid  f<'ver  is  characteristic.      Kven 

from  the  beginning  there  is  a  drowsy,  listless  appearance  with  heavy  eyes.  If, 
however,  headache  be  severe  or  fever  high  at  the  ousel,  the  expression  at  that 
time  may  be  excited  and  anxious,  the  eyes  bright,  and  liie  pu|)ils  <lilaled.  In 
verv  miid  cases  the  physiognf)my  n>ay  be  but  little  al(<'red  at  any  time. 

When  the  disease  is  fully  develo|)e(l,  if  of  the  ordinary  type,  the  patient 
lies  quietlv,  more  commoidy  upon  the  back,  with  the  eyes  often  closed,  and 


70  TYPHOID    FEVER. 

witli  a  peculiar  placid,  sleepy,  and  heavy  expression,  unless  there  be  active 
delirium,  when  jactitation  may  be  marked.  The  face  is  often  pallid  or  there 
may  be  a  circumscribed  flush  on  one  or  both  cheeks.  If  confined  to  one  side, 
this  may  indicate  a  higher  degree  of  congestion  of  the  corresponding  lung. 
The  flush  comes  and  goes,  and  is  often  brought  out  or  made  worse  by  the 
administration  of  food  or  stimulant. 

Tlie  general  strength  of  the  patient  is  usually  prostrated  from  the  begin- 
nino-.  In  crrave  cases  weakness  becomes  so  extreme  as  the  disease  advances 
that  the  patient  lies  utterly  helpless  on  his  back  or  slides  down  in  bed.  In 
very  mild  cases,  on  the  other  hand,  tliere  may  be  but  very  little  prostration. 
The  patient  may  be  about  or  may  rebel  against  confinement  to  bed.  Cases  are 
met  with  in  wliich  the  patient  has  kept  about  until  very  sliortly  before  death. 

Emaciation  frequently  becomes  great,  or  even  extreme  in  cases  which  have 
lasted  several  weeks.  According  to  the  studies  of  Cohin,  there  takes  place  at 
first  a  systematic  loss  of  weight,  varying  with  individuals,  the  loss  bearing  a 
unifi)rra  relation  to  the  course  of  the  temperature.  Later  the  patient  begins 
to  gain  weight,  the  constant  increase  being  an  evidence  of  convalescence. 
Zieniec  found  as  a  result  of  the  study  of  384  cases  that  there  was  an  average 
daily  loss  of  weight  of  0.6  per  cent,  which  continued  while  the  fever  lasted 
and  even  longer.  In  the  event  of  delirium  or  other  threatening  symptoms, 
or  of  the  development  of  complications,  the  daily  loss  became  1  to  1|  per 
cent.  If  the  increase  in  weight  during  convalescence  suddenly  ceased,  a 
relapse  was  probal)ly  indicated.  In  fatal  cases  the  total  loss  was  22  per  cent, 
of  the  body  weight. 

Skin,  Muscles,  etc. — The  skin  is  often  persistently  hot  and  dry  throughout 
the  whole  course  of  the  disease,  but  more  frequently  more  or  less  sweating 
occurs.  There  may  be  sudden  flushings  or  sudden  outbursts  of  perspiration. 
Sweating  is  more  common  in  typhoid  fever  than  in  almost  any  other  of  the 
acute  diseases  except  malaria,  relapsing  fever,  and  rheumatism.  It  is  usually 
slight,  occurring  at  night  or  on  awakening  in  the  morning  or  after  the  employ- 
ment of  the  bath,  but  it  may  develop  at  other  times,  may  be  limited  to  the  '■ 
face  and  head,  or  may  aflect  also  the  trunk  or  extend  to  the  entire  surface. 
In  severe  cases,  marked  by  a  high  degree  of  nervous  ataxia  and  exhaustion, 
the  body  may  be  bathed  in  sweat  continuously  for  many  hours  or  even  for 
several  days.  A  special  sudoral  form  of  typhoid  fever  has  even  been,  though 
unn'3(!essarily,  described  by  some  observers. 

The  characteristic  eruption  of  typhoid  fever  demands  close  study,  as  upon 
it  the  diagnosis  dejiends  in  many  cases.  It  consists  of  isolated  round  or  len- 
ticular, rose-colored,  slightly  elevated  spots,  which  first  appear  usually  on  the 
seventii  or  eighth,  but  occasionally  not  until  the  tenth  or  twelfth,  day  of  the 
disease,  and  then  continue  to  make  themselves  visible  in  successive  crops. 
They  are  rarely  to  be  discovered  after  the  middle  of  the  third  week.  They 
are,  as  a  rule,  first  found  upon  the  upper  jiart  of  the  abdomen  and  lower 
part  of  the  chest,  and  may  be  limited  to  that  region.  Occasionally  these 
parts  do  not  exhibit  any  rash,  while  other  portions  of  the  body  do.     The 


CONSIDERATION    OF  SPECIAL    SYMPTOMS.  71 

spots  often  also  ajipear  on  the  sides  of  the  trnnk  and  on  tlie  back,  and 
sometimes  upon  the  extremities.  In  very  rare  instances  they  are  spread 
over  the  entire  snrface,  and  I  have  seen  face,  trunk,  and  extremities  ehisely 
dotted  over  with  them.  When  tluis  copious  the  spots  may,  to  a  sH;j:ht 
extent,  be  confluent  by  twos  and  threes  by  the  edges.  They  are  soft  and  very 
slightly  elevated  papules  of  a  pale,  rose-red  color,  varying  in  diameter  from 
1|  to  2  or  3  lines,  disappearing  rapidly  on  pressure  and  returning  ])romptIy 
when  the  pressure  is  removed.  Each  spot  lasts  three  to  five  days,  and  then 
gradually  fades,  leaving  sometimes  a  brownish  stain.  Fresh  crops  appear  at 
intervals  of  three  to  five  days.  There  is  no  uniformity  in  the  amount  of 
eruption  nor  in  the  number  of  successive  crops,  nor  does  the  extent  of  eruption 
or  the  number  of  crops  or  of  individual  spots  bear  any  relation  to  the  gravity 
of  the  case.  Murchison  has  counted  as  many  as  one  thousand  spots  in  a  single 
case.  Generally,  however,  the  number  is  quite  limited,  and  careful  search  may 
sometimes  fail  to  detect  more  than  two  or  three  spots  during  the  whole  course 
of  the  disease. 

The  eruption  is  sometimes  entirely  absent  throughout  the  case.  This  hap- 
pens oftener  in  children  than  in  adults.  Mm-chison  reports  its  presence  in 
4606  of  tlie  5988  cases  of  typhoid  fever  which  occurred  in  the  liondon  Fever 
Hospital  during  twenty-three  years,  and  probably  careful  search  would  have 
shown  it  present  in  still  more  of  them.  Eichhorst  failed  to  miss  it  entirely  in 
over  one  thousand  cases  under  his  own  observation. 

Although  I  admit  that  the  observation  is  doubtfid,  owing  to  possible  want 
of  sufficiently  frequent  and  careful  search,  it  is  my  opinion  that  in  diircrent 
outbreaks  and  in  different  seasons  there  may  be  great  difference  in  the  amount 
of  the  eruption,  and  that  in  some  of  our  epidemics  it  has  not  been  extremely 
rare  for  the  typical  typhoid  spots  to  be  almost  or  entirely  absent,  and  this 
especially  in  young  children. 

We  should  never  conclude  that  no  rash  is  i)resent  until  after  repeated  and 
carefid  examination,  not  only  of  the  abdomen  and  chest,  but  of  the  back  and 
thighs  as  well.  The  importance  of  this  critical  examination  cannot  be  over- 
estimated. Occasionally  some  of  the  rose-colored  spots  may  be  capped  by  a 
small  vesicle  with  tiu'bid  contents. 

Certain  accidental  eruptions  may  be  seen  in  typiioid  fever,  and  it  is  import- 
ant not  to  confound  these  with  the  true  rash. 

Sudamina,  or  minute  pearly  vesicles,  occur  more  frequently  in  thi-^  tliiin  in 
any  other  of  the  infectious  diseases.  They  arc,  ho\v<vcr,  in  no  sense  charac- 
teristic of  it,  since  they  may  a|)|K'ar  in  any  :ilVc<-tinn  thai  is  attended  by 
copious  sweating.  They  are  as  likely  to  develcj)  in  mild  as  in  severe  eases 
of  typhoid,  and  may  be  present  at  almost  any  stage  of  tlie  disease,  though  they 
are  not  usually  met  with  until  .•iH-r  the  twelfth  day.  They  occur  most  com- 
monly on  portions  of  tlie  surface  where  the  cuticle  is  lender  and  where  ihere 
is  normally  a  tendency  to  pers|)irati(.ii.  Thus  llu-y  are  seen  about  the  cpigas- 
trimn,  the  hypoch(.n(iriac  regions  llw  axillie,  the  neci<,  or  about  the  groins 
and  the  inner  surface  (^f  the  thigli-.     They  arc  so  minute  and  deUcatc  that   it 


72  TYPHOID   FEVER. 

is  often  necessary  to  view  the  surface  obliquely  and  in  a  good  light  in  order  to 
detect  them,  and  they  may  sometimes  be  perceived  by  the  finger  when  they 
cannot  easily  be  distino;uished  by  the  eye.  In  some  cases  they  are  very 
copious,  and  may  appear  in  several  successive  crops.  As  sweats  are  not 
uncommon  in  typhoid  fever,  the  appearance  of  sudamina  cannot  be  regarded 
as  heralding  a  break  in  the  pyrexia. 

The  contents  of  the  sudamina  may  later  become  turbid  or  milky  ;  so  that, 
as  they  dry  up,  thin,  grayish  scales  are  formed,  which  readily  desquamate. 
Slight  desquamation  may  also  occur  in  cases  in  which  the  rose-colored  spots 
have  shown  a  tendency  to  fade  very  slowly. 

An  erythematous  eruption  of  a  faint  scarlet  color  is  sometimes  present  in 
the  first  week  of  typhoid  fever,  and  has  even  been  mistaken  for  the  rash  of 
scarlet  fever.  It  is  particularly  liable  to  occur  on  the  abdomen  and  chest,  but 
may  sometimes  be  detected  on  the  extremities  as  well.  Petechise  rarely  occur, 
and  oftener  develop  independently  of  the  rose-spots  than  exist  as  transforma- 
tions of  them.  Urticaria  is  sometimes  seen.  Herpes  labialis  occurs  occasion- 
ally, but  by  no  means  so  often  as  in  cerebro-spinal  fever  or  malarial  fever. 
During  the  height  of  the  disease  it  is  often  possible  to  elicit  a  distinct  red 
streak  with  white  edges  by  drawing  the  finger  across  the  cheek  or  brow  :  this 
closely  resembles  the  tdche  cerebrale  of  meningitis. 

It  is  pertinent  to  mention  the  occasional  occurrence  of  subcutaneous  mot- 
tling. This  is  seen  especially  where  the  skin  is  very  fair  and  sensitive,  and  is 
apparently  a  vaso-motor  phenomenon  occasioned  by  exposure  of  the  surface 
of  the  body.  Portions  of  the  skin  are  unusually  white,  while  there  is  in  other 
places  a  more  or  less  extensive  pinkish  injection,  thus  producing  a  mottling 
wiiich  at  times  is  extremely  marked.  It  has,  however,  no  special  significance. 
The  same  may  be  said  of  the  pale-blue,  subcuticular  patches,  "  peliomata,"  or 
*'  tdches  bleudtrefi "  of  French  writers.  Thev  vary  in  diameter  from  three  to 
eight  lines,  are  of  irregularly  rounded  form,  not  at  all  elevated,  of  a  uniform 
tint  throughout,  and  not  affected  by  pressure.  They  are  most  abundant  on  the 
abdomen,  chest,  and  thighs,  and  their  appearance  is  often  very  striking.  They 
are  by  some  referred  to  the  action  of  body-lice. 

(Edema  of  the  skin  of  portions  of  the  body  may  develop  in  typhoid  fever 
as  a  result  of  several  causes,  prominent  among  which  is  venous  obstruction. 
Nephritis  and  aneemia  may  also  produce  a  more  general  oedema. 

It  has  been  claimed  that  the  skin  exhales  a  peculiar  odor  in  typhoid  fever. 
It  was  described  as  "of  a  semicadaverous  and  musty  character"  by  Nathan 
Smith.  A  number  of  writers  agree  that  a  peculiar  odor  is  present,  although 
perhaps  more  deny  its  existence.  I  atli  myself  convinced  that  a  characteristic 
odor  is  often  to  be  noticed  about  patients  with  the  disease,  especially  in  cases 
attended  with  sweatin<r. 

Temperature. — The  course  of  the  fever  presents  many  variations  and  irregu- 
larities ;  still,  the  careful  study  of  a  large  number  of  temperature-charts  shows 
that  the  pyrexia  is  more  or  less  characteristic.  For  our  first  knowledge  of  this 
fact  we  are  largely  indebted  to  Wunderlich.    The  accompanying  chart  (Fig.  3) 


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74  TYPHOID    FEVER. 

represents  diagrammatically  what  may  be  called  the  typical  pyrexia.  In  the 
early  stages  of  the  disease  the  curve  exhibits  a  gradual  ascent,  occupying  about 
one  week,  during  which  each  successive  daily  maximum  and  minimum  is  from 
one  and  a  half  to  two  degrees  higher  than  the  corresponding  points  of  the  pre- 
vious day.  By  this  step-like  ascent,  with  a  daily  variation  likewise  of  fully  one 
and  a  half  to  two  degrees,  a  temperature  of  103°  to  104°  F.  is  reached  by  the 
close  of  the  first  week  or  sometimes  earlier.  Following  this  initial  period 
there  is  present,  for  about  two  weeks,  a  febrile  movement  of  a  more  uniform 
severity,  often  spoken  of  as  the  fastigium.  The  maximum  daily  temperature 
now  oscillates  about  the  maximum  temperature  of  the  preceding  period.  The 
morning  remissions  are  much  less  marked,  although  the  daily  range  is  still 
one  to  two  degrees.  The  course  of  the  fever  during  this  period  is  marked 
by  occasional  fluctuations  in  which  the  temperature  drops  considerably  below 
the  average  or  else  rises  to  the  point  of  hyperpyrexia.  During  the  third  week 
the  fever  begins  to  fall  gradually,  but  by  more  irregular  steps  than  it  showed  in 
the  initial  rise.  In  a  typical  case  the  evening  exacerbations  are,  for  a  time,  as 
great  as  before,  but  the  morning  remissions  become  daily  more  marked.  Very 
soon  the  evening  maximtmis  also  begin  to  grow  less  by  about  half  a  degree 
every  day,  while  the  morning  remissions  are  still  more  decided.  There  may 
be  a  difference  of  as  much  as  two  to  four  degrees  between  the  daily  maximum 
and  minimum,  and  by  the  close  of  the  third  week  or  in  the  fourth  week  the 
morning  temperature  is  nearly  or  quite  normal,  or  even  sometimes  subnormal, 
though  an  evening  exacei'bation  is  still  present.  The  pyrexia  thus  often  has  a 
somewhat  intermittent  character.  The  evening  temperature  continues  to  fall 
gradually,  and  with  considerable  regularity  in  typical  cases  the  normal  is  attained 
about  the  twenty-eighth  day  of  the  disease.  It  is  not  unusual  during  the  period 
of  defervescence  to  have  an  evening  maximum  higher  than  that  of  the  previous 
day,  but  followed  by  a  more  abrupt  fall  on  the  following  day. 

While  a  temperature  curve  possessing  these  features  may  be  regarded  as  the 
type,  it  must  be  understood  that  there  are  many  variations,  and  that  a  typical 
temperature  chart  is  not  often  seen.  This  will  be  understood  when  the  com- 
plex character  of  the  pyrexia  in  typhoid  fever  is  considered.  Not  only  is  there 
the  general  infectious  process,  with  the  morbid  chemical  changes  in  the  blood 
and  tissues  and  the  disordered  nervous  action  affecting  the  production  and  dis- 
sipation of  caloric,  these  acting  as  the  exciting  causes  of  the  primary  fever, 
but  there  are  often,  even  from  an  early  period  in  the  disease,  widespread  lesions 
which  develop  with  irregular  rapidity  and  influence  powerfully  the  febrile 
movement,  producing  what  may  be  called  the  secondary  fever.  In  addition  to 
these  is  the  operation  of  numerous  and  varied  accidental  factors  influencing  the 
temperature  curve,  such  as  indiscretions  in  diet,  the  occurrence  of  intestinal 
haemorrhage,  temporary  nervous  excitement,  profuse  diarrhoea,  free  epislaxis, 
and  the  development  of  complications.  I  know  of  no  disease  in  which  it  is 
more  difficult  to  appreciate  the  origin  and  meaning  of  the  pyrexia. 

In  certain  rare  cases  a  high  temperature,  even  105°  F.,  may  prevail  almost 
continuously,  day  after  day,  for  two  weeks,  and  yet  be  unassociated  with  any 


CONSIDERATIOX   OF  SPECIAL    SYMPTOMS.  75 

grave  nervous  symptoms  or  evidences  of  heart  failure.  I  have  observed  this 
most  frequently  in  young  and  sensitive  women,  in  whom  it  was  ajiparently  thie 
to  a  peculiar  disturbance  of  the  nervous  system,  since  there  were  no  marked 
pulmonary  or  intestinal  symptoms  to  explain  any  considerable  portion  of  the 
elevation.  On  the  other  hand,  it  is  not  exceptional  to  meet  with  cases,  espe- 
cially of  patients  of  phlegmatic  disposition,  where  all  the  symptoms  are  fairly 
well  marked,  and  yet  the  temperature  does  not  exhibit  a  corresponding  rise. 
Undoubtedly,  there  is,  however,  a  general  correspondence  between  the  gravity 
of  the  case  and  the  height  of  the  fever ;  and  this  is  true  whether  the  attack 
owes  its  severity  to  a  high  degree  of  infection  or  to  a  marked  development  of 
local  lesions.  Cases  where  the  temperature  is  throughout  little  above  the  nor- 
mal are  generally  of  mild  type,  although,  as  will  be  seen  later,  there  is  danger 
in  them,  as  in  others,  of  grave  complications  arising. 

The  most  characteristic  feature  of  the  temperature  curve  of  typhoid  fever 
is  the  gradual  initial  rise.  This  is  im|)ortant  in  its  bearing  on  prognosis,  l)ut 
especially  in  relation  to  diagnosis.  There  are  many  cases  of  influenza  and 
other  affections  in  which,  about  the  close  of  the  first  week,  the  symptoms 
closely  resemble  those  of  typhoid  fever,  but  in  which  the  fact  of  a  more 
abrupt  onset  is  a  guide  to  the  avoidance  of  a  serious  error.  It  must  not  be 
forgotten,  however,  that  a  rapid  initial  rise  in  temperature  to  103°  or  104°  F., 
with  or  without  preceding  chill,  may  occur  in  typhoid  fever  also.  This  is,  at 
times,  met  with  in  very  grave  cases,  but  it  may  also  be  noticed  in  those  of 
ordinary  severity,  especially  in  children  or  when  there  is  an  unusual  degree 
of  pulmonary  or  gastro-intestinal  irritation  at  the  beginning  of  the  attack. 
An  implicit  dependence  upon  the  typical  mode  of  ascent  during  the  first  week 
may  readily  lead  to  mistakes.  As  an  illustration  of  the  caution  requisite  I 
may  mention  two  cases  of  typhoid  seen  in  consultation  as  these  pages  go 
through  the  press.  Of  four  children — two  girls  aged  nineteen  and  eight, 
respectively,  and  two  boys  aged  seventeen  and  fifteen,  respectively — the  older 
girl  was  taken  suddenly  ill  in  the  night  with  vomiting,  and  the  next  morning 
had  a  fever  of  105°  F. ;  the  younger  boy  was  taken  ill  'the  following  morning, 
and  before  night  his  temperature  reached  104.6°  F.  The  girl,  on  subsequent 
inquiry,  stated  that  she  had  not  felt  bright  and  strong  for  a  week,  l)nt  twenty- 
four  hours  before  the  onset  she  had  been  to  a  large  dinm  i-p;irty.  The  boy 
had  continued  to  bathe  in  the  ocean  :m<i  to  play  tennis  imtil  the  day  preced- 
ing the  attack.  It  is  quite  certain  that,  had  t!ie  temperature  Ixcn  taken  regu- 
larly during  the  ])revious  week,  some  slight  ascending  fever  w(»nld  have  been 
found,  since  in  both  cases  within  thirty-six  hours  of  the  a|)parently  abrupt 
onset  copious  eriq)tion  api)eare(l,  showing  that  the  seventh  <.r  eighth  day  of 
the  disease  had  i)robably  been  reached.  Yet  for  the  practical  |)urpose  of  early 
diagnosis  the  attacks  seemed  as  sudden  as  though  of  acute  gastritis. 

The  flu(;tuations  which  occur  during  the  second  and  third  weeks  are 
difficult  of  ex])lanation.  As  already  stated,  the  curve  usually  i)resent,s 
marked  diurnal  variations  of  from  one  degree  to  two  degrees  betwe<>n  the 
mininnim   and   maximun).     The  shorter  the    tim.;   that  the   temperature  re- 


76  TYPHOID    FEVER. 

mains  high  in  each  twenty-four  hours,  the  better  is  the  fever  borne  as  a 
rule.  The  indication  is  unfavorable  when  a  high  temperature  is  maintained 
almost  continuously.  On  the  other  hand,  extreme  variations,  as  from  three 
and  a  half  to  five  degrees,  are  usually  associated  with  nervous  atony  and 
with  marked  sepsis  from  the  intestinal  ulceration.  The  most  extreme  daily 
variations  of  temperature  I  have  noted  in  this  disease  amounted  to  seven 
degrees  for  several  days  in  succession  in  a  fatal  relapse  complicated  by  exten- 
sive catarrhal  pneumonia.  In  some  cases  the  appearance  of  successive  crops 
of  eruption  and  the  variation  in  the  intensity  of  the  abdominal  symptoms  cor- 
respond with  exacerbations  of  fever,  and  suggest  a  relation  between  the  latter 
and  the  varying  intensity  of  the  intestinal  lesion. 

Hyperpyrexia,  or  fever  above  105°  F.,  is  much  less  common  in  typhoid 
fever  than  in  typhus,  scarlet,  or  relapsing  fever.  When  present  it  usually 
indicates  a  high  degree  of  danger,  and  the  cases  in  which  it  occurs  more 
than  a  few  times  exhibit  a  large  percentage  of  mortality.  Nevertheless,  it 
is  not  infrequent  to  have  recovery  follow  where  a  temperature  of  106°  F. 
has  been  reached  several  times  during  an  attack,  provided  that  the  fever  has 
not  remained  too  continuously  so  high.  Very  high  initial  temperatures  indi- 
cate intense  infection  or  violent  nervous  disturbance,  or  an  early  complication, 
such  as  marked  gastric  or  pulmonary  catarrh.  During  the  second  or  third 
week  hyperpyrexia  is  more  common  than  at  any  other  time.  When  the  tem- 
perature rises  with  less  decided  remissions  toward  the  close  of  the  second  week, 
or  remains  high  during  the  third  and  fourth  weeks,  it  indicates  continuance  of 
grave  lesions  or  the  occurrence  of  reinfection  ;  and  such  cases  are  very  unfa- 
vorable. As  death  approaches  it  is  not  unusual  to  note  a  progressive  rise  of 
temj)erature  (see  Fig.  4.),  which  may  reach  107°  or  even  above  110°  F., 
as  in  a  case  reported  by  Wunderlich.  In  such  cases  the  body  remains  warm 
for  a  long  time  after  death.  On  the  other  hand,  when  death  is  about  to  take 
place  by  collapse  the  temperature  sinks  to  normal  or  even  below  it. 

It  is  important  to  observe  the  time  when  the  daily  maxima  occur.  The 
study  made  by  Ampugnani  of  hourly  charts  from  200  cases  of  typhoid  fever 
shows  that  the  maximum  temperature  occurred  between  three  and  six  o'clock 
in  the  afternoon.  The  maximum  is  followed  by  a  gradual  fall  during  the 
night,  so  that  the  minimum  is  reached  between  four  and  eight  o'clock  in 
the  morning. 

The  tolerance  of  the  fever  by  the  patient  de})ends  much  upon  the  length  of 
the  remission.  There  is  often  a  marked  difference  between  successive  days  in 
this  respect. 

Some  cases  present  two  maxima  in  each  twenty-four  hours,  the  tempera- 
ture pursuing  a  very  rapid  and  irregular  up-and-down  course.  The  tempera- 
ture is  said  to  be  inverted  when  the  daily  maximum  occurs  in  the  morning 
and  the  minimum  in  the  evening.  This  is  not  unusual  in  cases  occurring 
under  the  age  of  twelve  years.  It  may,  however,  be  present  at  any  period  of 
life,  and  has  no  special  significance. 

There  is  no  crisis  or  abrupt  fall  of  temperature  in  the  normal  curve  of 


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78  TYPHOID    FEVEB. 

typhoid  fever.  Any  sudden  drop  must  therefore  be  viewed  with  suspicion. 
It  may  indicate  the  approaching  development  of  a  serious  complication,  as 
when,  owing  to  some  carelessness  in  nursing,  the  patient  has  been  allowed  to 
become  chilled  and  there  is  to  be  an  attack  of  ])neumonia.  It  may  mark  the 
occurrence  of  severe  intestinal  hsemorrhage,  and  the  temperature  may  fall  sud- 
denly as  much  as  five,  seven,  or,  in  rare  cases,  even  nine  or  ten  degrees,  with 
marked  evidences  of  shock,  before  the  bloody  discharges  occur  to  furnish  the 
positive  explanation.  It  may  attend  the  occurrence  of  a  perforation  of  the 
intestine.  Occasionally  a  fully-developed  case  which  is  pursuing  apparently 
the  usual  course  will  culminate  early  in  the  third  week  in  a  rather  rapid  fall 
in  temperatiu-e  to  the  normal,  and  this  be  followed  by  uninterrupted  convales- 
cence. These  abortive  cases  may  owe  their  short  duration  to  the  slight  degree 
of  intestinal  lesion  and  to  the  early  stoppage  of  infection  from  that  source,  as 
well  as  to  the  absence  of  the  secondary  fever  which  extensive  ulcerative  pro- 
cesses would  naturally  produce. 

It  is  never  safe  to  consider  the  disease  ended  until  the  temperature  has  been 
at  or  a  little  below  normal  both  morning  and  evening  for  several  days  in  suc- 
cession. If  the  temperature  continue  to  rise  even  to  99f  °  or  99f  °  F.,  though 
the  morning  temperature  be  normal  or  somewhat  subnormal,  it  must  be  under- 
stood that  some  lingering  trace  of  the  disease  is  still  in  the  system  or  that  some 
complication  is  present.  Occasionally  a  post-typhoid  anaemia  may  account  for 
this  daily  slight  evening  rise,  or  the  evening  fever  is  purely  nervous  in  origin, 
and  will  be  cured  by  allowing  the  patient  to  abandon  the  bed. 

It  often  haj)pens  that  after  the  temperature  has  fallen  to  the  normal  there 
will  be  an  irregular  rise,  which  on  close  examination  will  be  found  due  to  the 
occurrence  of  phlebitis,  periostitis,  a  latent  pleurisy,  or  some  other  sequel.  In 
other  instances,  after  convalescence  has  been  established  for  two  or  three  days, 
the  temperature  will  rise  again  rather  suddenly,  and  remain  elevated  for  a  day 
or  two  without  any  severe  constitutional  disturbance  being  present  and  without 
the  action  of  any  complication  or  sequel.  These  recrudescences  are  due  to 
various  slight  causes,  as  fatigue,  excitement,  indiscretions  in  diet,  etc.  In  the 
event  of  a  true  relajise  of  the  disease  the  temperature,  after  being  strictly 
normal  for  several  days,  will  begin  for  a  second  time  a  gradual,  step-like 
ascent,  reaching  103°  or  104°  F.  by  the  sixth  or  seventh  day,  and  then  pur- 
sue, for  a  week  or  ten  days,  a  fluctuating  course  similar  to  that  in  the  original 
attack ;  this  being  followed  by  a  gradual  decline  to  the  normal  again.  Lastly, 
there  are  certain  cases  of  tyjihoid  fever,  to  which  reference  will  be  made  again, 
in  which  the  temperature  never  rises  above  normal. 

The  Nervous  Symptoms  deserve  minute  study.  It  occasionally  hajipens  that 
throughout  the  course  of  a  case  the  mind  will  remain  clear  and  the  special 
senses  almost  normal,  but  such  instances  are  excejitional.  Usually  there  ap- 
])ears  at  an  early  stage  of  the  disease  a  mild  degree  of  drowsy  dulness,  styled 
hebetude.  The  patient  looks  and  seems  sleepy,  and  will  lie  quietly,  with  the 
eyes  closed,  paying  little  or  no  attention  to  his  surroundings  and  rarely  making 
any  remark.     If  addressed  he  opens  his  eyes  leisurely,  and  in  a  slow  and 


COXSIDERATIOX   OF  SPECIAL    SYMPTOMS.  79 

deliberate  voice  returns  an  api)ru])riate  answer.  He  seemingly  relishes  liqnids 
when  given,  yet  would  go  a  long  time  without  asking  for  nourishment  or  drink. 
Wlien  roused  he  soon  falls  back  again  into  the  same  somnolent  state,  so  that  it 
is  ]K)ssible  to  administer  food  and  remedies  at  regular  intervals  without  inter- 
fering with  his  rest. 

Headache  is  one  of  the  most  frequent  of  the  symptoms  of  tvphoid  fever, 
and  is  often  complained  of  bitterly  at  the  onset.  It  is,  as  a  rule,  most  severe 
in  the  occipital  and  cervical  region,  but  at  times  extends  anteriorlv.  It  may 
be  so  violent  as  to  arouse  fears  of  meningitis,  especially  when  combined,  as  it 
sometimes  is,  with  retraction  of  the  head,  twitching  of  the  nuiscles,  and  allied 
symptoms.  In  some  cases  it  persists  throughout  the  greater  part  of  the  attack 
and  constitutes  the  most  troublesome  symptom.  More  connnotdy  it  subsides 
as  hebetude  develops,  which  after  the  first  week  renders  the  patient  too  dull  to 
notice  it  clearly  even  if  it  exists.  Headache  appears  to  be  as  fre(|uent  in  chil- 
dren as  in  adults.  Its  presence  does  not  seem  to  be  any  indication  of  the 
severity  of  the  attack. 

Vertigo  often  accompanies  headache,  but  usually  disappears  with  it. 
AVakefulness  at  night,  with  restlessness,  is  usually  com|)lained  of  during  the 
early  portion  of  the  attack.  It  may  appear  again  later  in  the  disease,  asso- 
ciated with  wandering  or  more  violent  delirium.  It  is  at  times  a  troublesome 
svmptom,  and,  though  the  patient  may  seem  dull,  there  may  be  little  or  no 
actual  sleep.  If  this  condition  persist  exhaustion  is  apt  to  ensue.  It  is  most 
important  to  bear  this  fact  in  mind,  because  the  dull  ai)pearance  of  the  patient  \ 

may  mislead  the  attendants  into  the  belief  that  he  is  getting  sufficient  sleep. 
The  symptom  is  one  which  should  receive  early  and  efficient  treatment. 

Delirium  of  some  sort  may  be  observed  at  times  in  the  majority  of  cases. 
It  mav  be  present  from  the  start,  but  it  oftener  does  not  appear  until  toward 
the  close  of  the  second  week,  following  headache  and  somnolence  and  preceding 
stupor.  Its  mildest  form  is  simjily  a  slight  confusion  of  ideas,  particularly 
noticeable  toward  evening  or  during  the  night  or  on  awakening  from  sleep, 
the  patient  being  at  other  times  perfectly  rational.  The  most  characteristic 
form  is  that  of  the  wandering  type.  The  patient  talks  to  himself  ra])idly, 
softly,  and  unintelligibly,  and  often  appears  to  be  hdhling  a  conversation  with 
imaginary  persons;  and  this  delirium  may  last  nninterruj)tedly  for  hours. 

The  wandering  delirium  may  alternate  with  periods  of  somnolence,  or,  on 
the  other  liand,  there  may  be  outbreaks  of  active,  noisy  delirium,  which  are 
peculiarly  liable  to  be  attended  by  such  effiyrts  to  leave  the  bed  fhat  forcible 
restraint  becomes  necessarv.  Occasionally  maniacal  delirium  ••(•(  iirs  early  in 
the  disease.  It  has  sometimes  been  the  first  symjitom  noticed.  A  case  is 
reported  by  Motet  in  which  a  ])atient  was  sent  to  an  insane  asylum  before 
the  true  nature  of  the  febrile  disease  was  discovered. 

Even  when  the  patient  has  seemed  almost  rational  (hiring  \\\r  dny,  it  is 
necessary  that  a  close  watch  be  kept  during  the  night,  as  then  he  ofteri  dn-ams 
of  being  awav  from  home  and  that  he  is  summoned  to  return,  or  he  awakens 
with  the  notion  that  he  \^  not  in  his  own  rocm),  and  rises (juickly  to  go  thither. 


80  TYPHOID    FEVER. 

This  is  a  very  common  delusion,  and  in  this  confused  state  serious  accidents 
may  happen  to  the  patient  from  stepping  out  of  windows  or  falling  down  stairs 
while  trying  to  follow  some  imaginary  summons  or  to  escape  from  some 
a])parently  strange  and  uncomfortable  place.  It  is  necessary  to  impress  this 
fact  very  clearly  upon  the  attendants,  not  only  in  private  practice,  but  in  hos- 
pitals, since  fatal  results  from  this  source  are  not  infrequent. 

In  children  or  in  young  and  sensitive  women  a  violent  form  of  delirium  is 
sometimes  met  with  which  must  be  regarded  as  partly  hysteroidal  in  type. 
There  is  extreme  restlessness  and  agitation  of  the  whole  body ;  the  patient 
talks  rapidly  and  with  utter  and  wild  incoherence;  at  the  same  time  there  is 
a  ])eculiar  quality  of  voice  and  of  expression,  conjoined  with  a  less  degree  of 
violence  of  the  associated  symptoms  than  would  seem  naturally  to  accompany 
such  excessive  delirium  ;  which  indicates  the  presence  of  a  large  emotional  ele- 
ment.    Such  cases,  although  very  alarming  in  appearance,  recover  habitually. 

In  the  second  or  third  week  of  the  disease  in  severe  cases  somnolence,  which 
preceded  delirium  to  some  extent  and  then  alternated  with  it,  may  deepen  so 
as  to  replace  it  to  a  great  degree.  The  active  delirium  entirely  ceases,  and  only 
a  low,  muttering  form  remains.  Finally  the  patient  settles  into  a  state  of  more 
or  less  deep  coma. 

It  is  only  in  grave  cases  that  such  stupor  ensues  or  that  intelligence  is  so 
wholly  lost  that  it  becomes  impossible  to  rouse  the  patient  so  that  he  will  pro- 
trude the  tongue  when  requested.  Profound  stupor  may,  however,  exist  for 
fully  two  or  even  three  weeks,  and  then  gradually  clear  up  as  the  fever  declines 
and  the  case  approaches  convalescence.  Coma  vigil,  a  state  in  which  the 
patient,  although  in  deep  stupor,  lies  with  the  eyes  open,  fixed,  and  staring,  is 
much  more  rare  in  typhoid  than  in  typhus  fever.  It  indicates  intense  nervous 
irritation  combined  with  exhaustion,  and  is  of  grave  omen.  When  it  occurs 
it  is  usually  toward  the  close  of  fatal  cases  which  have  been  marked  by  violent 
nervous  symptoms. 

The  organs  of  special  sense  present  few  disorders.  Ringing  and  buzzing 
in  the  ears  are  frequent  in  the  early  stages,  and  allusion  has  already  been  made 
to  the  dulness  of  hearing  frequently  observed  in  the  early  days,  and  which  is 
apt  to  continue  as  a  marked  symptom.  This  deafness  usually  occurs  in  both 
ears,  and  is  due  partly  to  a  catarrhal  condition  of  the  Eustachian  tubes  and 
partly  to  the  blunted  mental  sense-perception.  Deafness  in  one  ear  is  apt  to 
be  a  more  serious  sympton.  Vision  is  rarely  affected.  Sometimes  there  is 
slight  haziness,  or  there  may  even  be  double  vision.  There  is  at  times  decided 
photophobia.  Injection  of  the  conjunctivse  is  rare.  The  pupils  are  usually 
dilated,  in  contradistinction  to  the  contracted  pupils  of  typhus  fever.  The 
dilatation  develops  in  the  latter  part  of  the  second  week,  and  very  often 
accompanies  delirium,  though  it  may  occur  without  it.  Occasionally  the 
pupils  are  unequal,  and  after  stupor  comes  on  they  may  become  much  con- 
tracted.    Strabismus  is  sometimes  seen. 

Epistaxis  is  a  common  symptom,  and  Is  often  one  of  the  earliest  ones, 
though  it  may  occur  at  any  period   in  the  disease.     It  may  vary  in  amount 


COXSIDEIiATIOX   OF  SPECIAL    .SYMPTOMS.  81 

froai  a  few  drops  only,  just  sufficient  to  stain  the  liandkcrcliief  or  the  pillow, 
to  a  haeniorrluiiro  of  a  profuse  nature. 

There  is  evidently  a  morbid  condition  of  the  nasal  mucous  membrane 
which  disposes  to  it,  and  which  is  aided  by  the  altered  crasis  of  the  blood. 
Even  when  no  blood  has  escaped,  the  nails  of  the  patient  may  show  traces 
of  it.  It  thus  has  considerable  diagnostic  value.  Although  epistaxis  occurs 
occasionally  in  other  infectious  diseases,  and  is  absent  in  some  cases  of  tvphoid 
fever,  it  is  incomparably  more  frequent  in  the  latter  affection  than  in  any 
other  acute  disease.  It  does  not,  as  a  rule,  afford  any  relief  to  the  symptom's 
of  the  disease,  and  is,  indeed,  rarely  free  enough  to  affect  the  system,  although 
I  have  occasionally  seen  apparent  temporary  relief  to  severe  headache  and  rest- 
lessness from  a  free  epistaxis  in  tlie  early  stages  of  the  disease.  On  the  other 
hand,  when  there  is  already  decided  debility  any  considerable  loss  of  blood 
is  to  be  dreaded.  In  hsemorrhagic  cases  epistaxis  is  one  of  the  commonest 
forms  of  bleeding,  and  even  where  there  is  no  blood  lost  from  any  other 
surface  epistaxis  may  be  so  profuse  and  obstinate  as  to  induce  dangerous 
or  fatal  exhaustion. 

The  sense  of  taste  is  often  greatly  impaired,  owing  both  to  the  blunted 
perception  of  taste  and  to  the  thick  coating  of  the  toiTgue. 

Cutaneous  hyperaesthesia  sometimes  occurs,  jnirticularly  in  women  and 
children,  but  it  is  not  seen  as  often  as  in  typhus  fever  or  cerebro-spinal  fever. 
It  may  be  so  severe  that  the  slightest  touch  causes  great  suffering.  It  can 
occur  at  any  time  during  the  attack.  Its  principal  seat  is  the  superficies  of  the 
alxlomen  and  the  lower  extremities.  Cutaneous  anaesthesia  has  been  reported 
in  rare  instances. 

With  the  headache  already  mentioned  there  is  at  times  violent  ])ain  extend- 
ing down  the  spine.  Tenderness  over  the  spinous  processes  may  be  associated 
with  this.  Pain  in  the  extremities,  particularly  the  legs,  is  of  quite  common 
occurrence,  especially  at  the  commencement  of  the  disease.  Toward  the  close 
of  the  first  week,  however,  it  subsides,  and  it  is  only  in  exceptional  cases  that 
much  pain  is  complained  of  in  the  later  periods.  As  a  ride,  patients  looking 
back  uj)on  their  attacks  of  typhoid  fever  do  not  speak  of  them  as  painful. 

Trenndousness  and  weakness  of  the  muscles,  as  seen  in  the  hands,  Iij)s,  and 
tongue,  are  very  often  present.  Most  marked  in  the  severer  cas(>s,  they  may 
occur  even  in  those  patients  whose  mental  faculties  are  entirely  preserved. 
They  are  commonest  in  the  old  and  feeble  and   in  the  intemperate. 

Clonic  spasmodic  movements  are  present  only  in  (he  later  periods  of  (he 
graver  cases.  Subsultus  tendinum  is  one  of  the  syiii|ii>iiii^  df  this  class,  as  is 
also  twitching  of  the  face.  The  condition  becomes  iikkI  ni.iikeil  iind  nearly  mw- 
stant  when  the  low  muttering  delirium  of  I  he  l.itter  stages  develops.  ("ar|>lio- 
logia  is  also  on(!  of  the  severer  symj)toms.  In  it  the  p.-itienl  gropes  in  the 
air  after  imaginary  objects  (jr  picks  at  the  bed-<.' lot  lies  as  though  to  remove 
something  from  them.  Obstinate  hiccough  may  be  seen  toward  the  last  stages 
of  grave  cases,  or  sometimes,  indeed,  as  an  (>arly  symptom,  it  is  usually  a 
sign  (}f  evil  omen.     General  convidsions  are  unusual,  being  chielly  met  with 

Vol.  I.— 6 


82  TYPHOID    FEVER. 

toward  tlie  end  of  grave  cases,  and  oftener  in  children  than  in  adults. 
Recovery,  however,  may  take  place  after  them. 

Rigidity  of  various  groups  of  muscles  is  frequently  seen  in  severe  cases. 
In  some  there  are  marked  retraction  and  stiifness  of  the  muscles  of  the  neck, 
and  even  of  those  of  the  spine.  This  may  be  as  marked  as  in  cerebro-spinal 
fevei-.  but  does  not,  nevertheless,  call  for  a  description  of  a  special  cerebro- 
spinal type  of  tvphoid  fever.  Sometimes  spasmodic  constriction  of  the 
muscles  of  the  pharynx  prevents  swallowing.  Trismus,  spasm  of  the  glottis, 
and  riinditv  of  the  extremities  have  also  been  reported.  I  have  noted  in  some 
cases  an  extreme  degree  of  general  muscular  rigidity,  with  a  fixed  ecstatic 
expression  of  fiice.  Tiiis  may  be  met  with  in  cases  of  hysterical  type,  when 
it  bodes  no  special  danger  ;  or,  on  the  other  hand,  it  may  be  seen  toward  the 
close  of  fatal  cases  where  tliere  has  been  great  nervous  irritation  in  the  earlier 
stages. 

According  to  Hughlings-Jackson  and  Money,  the  knee-jerk  is  never  absent 
in  typhoid  fever. 

The  Digestive  Symptoms  are  numerous  and  of  the  greatest  importance. 
There  is  no  other  disease  in  which  anorexia  is  more  marked  or  persistent.  It 
is  complained  of  during  the  initial  stage,  and  lasts  until  convalescence  begins. 
Usually  it  is  only  an  indiiference  to  food  and  not  an  actual  aversion,  and  it  is 
generally  possible  to  administer  a  fair  amount  of  nourishment,  especially  in 
the  form  of  milk  or  light  broth  which  has  no  decided  taste.  In  mild  cases, 
where  there  is  an  unusual  retention  of  intelligence  throughout  the  disease,  I 
have  frequently  observed  continuance  of  more  or  less  decided  appetite.  Thirst 
is  generally  marked  in  the  early  stages,  but  later,  when  the  mental  faculties 
are  greatly  obtunded,  water  is  no  longer  asked  for. 

The  tongue,  as  oftenest  seen  in  typhoid  fever,  is  enlarged  and  flabby,  not 
rarely  tooth-marked  around  the  edges,  and  with  a  whitish  or  yellowish  coat. 
The  papillae  are  not  especially  prominent.  The  edges  are  generally  unnaturally 
red,  and  there  often  is  a  red  triangular  area  near  the  tip.  At  about  the  middle  or 
end  of  the  second  week  it  may  lose  its  coating  entirely  or  in  spots,  and  become 
bright-red,  dry,  clean,  glazed,  and  sometimes  fissured  ;  but  more  frequently  it 
grows  brownish,  especially  in  the  centre,  and  may  finally  become  coated  all 
over  with  a  thick,  cracked,  brownish  crust  which  renders  its  protrusion  very 
difficult.  Toward  the  beginning  of  convalescence  it  becomes  gradually  more 
moist  and  the  crust  is  slowly  gotten  rid  of.  It  is  not  at  all  unusual,  however, 
in  cases  of  moderate  severity  for  the  tongue  to  remain  moist  and  only  slightly 
coated  throughout  tlie  wdiole  course  of  the  disease. 

The  viscidity  of  the  secretion  of  the  mouth  causes  it  to  dry  and  be  depos- 
ited as  sordes  upon  the  teeth  and  lips.  This  is  particularly  liable  to  occur 
M-hon  the  typhoid  state  is  well  developed,  but  is  not  at  all  characteristic  of 
typhoid  fever  alone.  The  lips  are  generally  dry,  and  often  crack  and  bleed 
if  picked.  The  gums  rarely  bleed.  The  pharynx  is  commonly  the  seat  of 
marked  catarrhal  irritation,  and  the  mucous  membrane  is  swollen  and  con- 
gested and  secretes  a  thick  mucus.     The  tonsils  may  be  enlarged  at  the  same  time. 


CONSIDEliATION   OF  SPECIAL    SYMPTOMS.  83 

Nausea  and  vomiting-  sometimes  occur,  especially  at  liie  be^nmiing,  but  arc 
not  common,  in  my  experience,  unless  excited  by  injudicious  fmliuo;  or  medi- 
cation. Late  in  the  disease  vomiting  is  even  more  rare,  except  as  the  result  of 
peritonitis  or  of  ulcer  of  the  stomach.  The  morbid  irritability  of  the  stomaeli 
is  at  times  marked,  and  I  have  seen  violent  nervous  symptoms,  even  convul- 
sions, produced  by  minute  amounts  of  solid  food.  Rarely  vomiting  is  so  per- 
sistent that  death  may  follow  from  exhaustion. 

Tympanites  is  a  very  frequent  symptom.  Generally  it  does  not  develop 
before  the  second  week,  but  sometimes  is  seen  earlier  than  this.  It  varies  in 
degree  from  slight  meteorism  to  extreme  distension,  suflieient  to  interfere  with 
breathing  and  heart-action  and  to  cause  extreme  distres.s.  It  is  generally  most 
marked  in  severe  cases,  especially  if  diarrha^a  be  a  j>romineut  symptom,  but  it 
may  develop  independently  of  this.  It  is  due  to  the  influence  of  the  intestinal 
ulceration  paralyzing  the  peristaltic  movements  of  the  bowel,  to  tiie  degenera- 
tion of  the  muscular  coat  of  the  bowel,  and  to  the  ])roduction  of  gas  from 
decomposition  of  food  and  of  the  intestinal  discharges.  Tympanites  once 
developed  is  apt  to  persist,  though  often  varying  in  degree  upon  ditlerent 
days. 

Abdominal  pain  and  tenderness  are  very  commonly  observetl.  The  ])ain 
may  be  due,  as  stated,  to  abdominal  distension  (»r  may  be  directly  produced  by 
the  ulceration  of  the  bowel.  Fugitive  griping  pains  often  occur  among  the 
earliest  symptoms.  Tenderness  on  pressure  is  chiefly  found  in  the  right  iliac 
fossa,  and  is  caused  by  the  intestinal  ulceration  in  this  region.  Xevertheless, 
severe  ulcer*ation  may  sometimes  be  present  without  producing  tenderness. 

Gurgling  is  often  elicited  by  jiressure  in  the  right  iliac  fossa,  and  is  due  to 
the  presence  of  gas  and  liquid  in  the  lower  part  of  the  ileum.  It  may  oceur 
in  any  disease  accompanied  by  diari'hcea. 

Diarrhoea  must  be  considered  one  of  the  cardinal  symptoms  of  typhoid 
fever.  It  may  be  one  of  the  early  manifestations  of  the  disease,  perhaps 
present  even  upon  the  first  day  of  the  onset,  or  possibly  among  the  prodromes, 
but  it  more  frequently  develops  toward  the  end  of  the  first  week,  and  some- 
times not  until  late  in  the  disease.  It  may  last  for  a  few  days  or  may  persist 
throughout  the  whole  attack.  Its  severity  varies  greatly,  the  movements 
numbering  two  to  four  daily  as  an  average  number,  but  in  many  cases  reai-h- 
ing  ten  or  twelve  or  even  more  in  the  twcnty-fi)ur  hoiu-s.  'V\\v  evaeuati(»ns 
are  rarely  accompanied  by  pain,  and  tencsnms  does  not  occur.  ()ceasi(.nally, 
brief  griping  pains  will  precede  each  movement  of  the  bowels,  and  I  have 
known  the  occurrence  of  frequent  painful  contractions  <W'  the  reetnm.  The. 
gravitv  of  the  case  is  in  direct  proportion  to  the  severitv  of  (h.-  diarrlMea, 
although  two  or  three  loose  movements  daily  need  eause  no  >p.vial  uneasiness, 
provided  thev  be  small  and  unattended  with  any  sympt.mis  of  .xhanstion. 

Even  in' cases  of  decide<l  severity,  however,  .liarrlm.:.  n.ay  be  .ntireiy 
absent.  In  mv  own  .'xpericnce  the  "bow.-ls  are  more  ofKi.  .,iiiri  tinn  is 
generallv  taught;  ami,  indeed,  constipation  is  not  r.niv  proent  t..  s.i.h  a 
degree  as  to  require  attention.      Kven   in  si.rh  eases,  l.owev.r.  tl..^   la.t   nuist 


84  TYPHOID    FEVER. 

be  borne  in  mind  that  the  intestinal  tract  of  every  patient  with  typhoid  fever 
is  in  an  irritable  condition,  and  that  drngs  given  to  open  the  bowels  act  with 

unusual  activity. 

The  severity  of  the  diarrhoea  bears  little  proportion  to  the  degree  of  the  ulcer- 
ation. A  very  extensive  ulcerative  process,  followed  by  perforation  or  fatal 
hemorrhage,  may  occur  in  cases  in  which  there  has  been  no  diarrhoea  or  any 
other  abdominal  symptom.  In  fact,  the  looseness  of  the  bowels  depends  rather 
on  the  degree  of  catarrh,  particularly  of  the  large  intestine,  than  upon  the  ulcera- 
tion. In  one  case  where  death  occurred  after  perforation  the  patient,  who  was 
sixtv-three  years  of  age,  had  throughout  such  constipation  that  firm  evacua- 
tions were  secured  on  alternate  days  by  enemas. 

The  ciiaracteristic  stools  of  typhoid  fever  are  of  a  light  ochre-yellow  color, 
thin,  offensive,  alkaline,  and  often  ammoniacal.  Their  appearance  often  sug- 
gests a  comparison  with  thin  pea-soup.  On  standing  they  separate  into  two 
layers,  the  upper  being  thin  and  serous  and  containing  albumin  and  soluble 
salts,  and  the  lower  being  a  flaky  sediment  consisting  of  remnants  of  food, 
blood-cells,  epitiielial  debris,  crystals  of  triple  phosphates,  and  sometimes  por- 
tions of  sloughing  tissue.  This  characteristic  appearance  of  the  evacuations 
is  best  seen  after  the  middle  of  the  second  week.  Before  this  the  passages 
are  more  apt  to  be  brownish  in  color.  Sometimes  the  stools  are  frothy  or 
pultaceous.  Blood  may  be  present  in  sufficient  quantity  to  give  them  a 
very  dark-red  or  almost  black  color.  In  some  cases  the  stools  are  passed 
involuntarily. 

Intestinal  haemorrhage  of  some  degree  is  a  symptom  seen  in  from  3  to  7 
per  cent,  of  all  cases,  according  to  different  estimates.  It  is  always  a  cause  of 
anxiety,  and  may  prove  a  symptom  of  the  greatest  gravity.  It  may  vary  in 
amount  from  a  few  drops  to  a  quantity  sufficient  to  prove  rapidly  fatal.  It 
occurs  oftenest  between  the  close  of  the  second  week  and  the  beginning  of  the 
fourth  week,  but  may  be  seen  as  early  as  the  fifth  or  sixth  day.  The  early 
haemorrhage  is  due  to  intense  congestion  of  the  intestine  or  to  disintegration 
of  blood  within  the  vessels,  and  is  usually,  though  not  always,  of  small 
amount.  It  appears  sometimes  to  be  the  result  of  a  haemorrhagic  diathesis, 
and  is  then  accompanied  by  epistaxis  and  haematemesis.  When  due  to  dis- 
organization of  the  blood  it  is  apt  to  be  combined  with  petechiae  and  bloody 
urine.  Tiie  bleeding  later  in  the  affection  is  produced  by  the  opening  of  small 
blood-vessels  as  a  result  of  the  intestinal  sloug-hinw. 

Hemorrhage  is  most  common  in  cases  which  have  previously  been  severe 
and  in  which  diarrhoea  has  been  marked.  The  blood  is  bright  red  if  passed 
at  once,  or  dark  and  clotted  or,  ])erhaps,  tarry  if  retained  for  several  days. 
Sometimes  extensive  internal  haemorrhage  takes  place,  and  death  occurs  with- 
out blood  having  been  voided  at  all.  The  symptoms  of  a  large  haemorrhage 
usually  come  on  unexpectedly.  They  consist  of  a  sensation  of  sinking  and 
faintness,  great  prostration,  pallor,  sudden  reduction  of  temperature  by  several 
degrees  and  even  to  below  normal,  feeble  pulse,  coldness  of  the  extremities, 
and  a  temporary  improvement  in  the  nervous  symptoms.     If  death  in  collapse 


r 


CONSIDEBATWy    OF  SPECIAL    SYMPTOMS.  85 

do  not  occur,  the  temperature  rises  ajrain  within  twentv-luur  lu.urs,  with  a 
reappearance  of  the  nervous  symptoms  as  they  existed' before  tlie  accidn.t. 

Occasionally  1  have  known  a  marked  rise  of  tempei-atuiT  to  pre<'ede  hy  a 
few  hours  the  occurrence  of  haemorrhage.  In  one  case  under  the  care  of  Dr. 
W.  R.  Batt,  which  was  apparently  doing  well  with  a  temperature  not  exceed- 
ing 102°  F.,  fever  increased  on  the  eighteenth  day,  and  on  the  twentieth  day 
the  temperature  reached  105°  F.  Hemorrhage  occurred  first  on  the  twenty- 
first  day,  and  within  thirty-six  hours  there  were  six  very  large  diseharges  of 
blood.  The  temperature  fell  gradually  to  97°  F.  This  was  I'ollowed  by  high 
fever  and  the  evidences  of  peritonitis.  Convalescence  w;us  not  (•omi)letcd  until 
the  one  hundred  and  fourth  day.  (See  Fig.  5). 

It  is  obviously  necessary  to  recognize  two  different  forms  of  iKuniorrhage  in 
typhoid  fever  which  are  of  widely  different  gravity,  because,  while  Graves  and 
Trousseau  do  not  seem  to  have  regarded  it  as  a  very  dangerous  symptom,  many 
observers  have  found  it  followed  by  death  in  a  very  large  proportion  of  cases. 
If  the  blood  passed  be  bright  in  color  and  small  in  amount,  and  if  there  be  no 
evidence  of  shock  to  the  system  nor  any  increasing  distension  of  the  abdonn-n 
due  to  accumulation  of  blood  and  development  of  gases,  there  is  ground  for 
hope  that  it  has  come  from  the  large  bowel  as  the  result  of  a  small  follicidar 
ulceration.  I  have  seen  many  such  instances  where  any  alarm  at  the  occur- 
rence of  a  haemorrhage  of  moderate  amount  has  proved  needless,  since  the 
favorable  course  of  the  case  was  in  no  way  disturbed  by  it.  So,  too,  even 
when  the  haemorrhages  are  large  and  re])eated  and  have  induced  most  alarm- 
ing collapse,  so  that  life  seems  almost  extinct,  the  case  is  not  necessarily  lost, 
since  reaction  may  be  secured  and  recovery  follow  a  cessation  of  the  dis- 
charges. 

Enlargement  of  the  spleen  is  present  in  most  cases.  It  begins  at  about 
the  middle  of  the  first  week,  is  greatest  at  about  the  cntl  of  the  second  week, 
and  diminishes  durinar  the  third  and  fourth  weeks.  It  is  often  vcrv  consider- 
able,  and  the  organ  may  even  reach  three  times  its  natural  size.  The  cnlargwl 
spleen  is  smooth,  not  indurated,  and  is  often  slightly  tender  on  pressure.  It 
can  usually  be  detected  by  careful  palpation  below  the  margin  of  the  ribs  from 
the  earliest  days  of  the  disease.  If,  however,  tympanitic  distension  develop,  it 
often  becomes  impossible  to  feel  the  s])]een  even  though  decidedly  enlarged. 
Increased  area  of  splenic  dulness  can  be  demonstrated  by  pcTcussion  even 
more  constantly,  and  it  is  only  where  tympanites  grows  extrenjc  that  carelid 
light  percussion  fails  to  detect  the  enlarged  organ. 

Of  the  circulatory  symptoms  there  is  nothing  cliaracteristic  in  thr  heart- 
sounds,  except  that  as  tiie  disease  advances  in  adynamic  eases  the  (luality  of 
the  first  sound  changes  and  approaches  that  of  the  second  sound,  while  a  I'aint 
systolic  murmur  may  become  audible.  The  true  eon<lition  ..f  ihe  eireul:it>.ry 
strength  of  the  patient  can  often  thus  be  best  determined  by  eonstantly  watch- 
ing the  nature  and  alterations  of  the  first  sound.  l»al|.il:ilion  of  the  heart  may 
result  from  the  disturbance  of  (he  nervous  system.  In  a  <".se  re.vnily  ui..ler 
ray  observation  there  were  daily  paroxysms  at  almost  the  same  hour,  att.'uiled 


Fig.  5. 


H.  B ,  male,  set.  3-1,  case  of  moderate  severity,  without  marked  diarrhoea,  began  Dec.  6th.  Tem- 
perature range  moderate  until  Dec.  24th,  when  it  began  to  rise,  reaching  105°  on  Dec.  '26th.  Hsem- 
orrhago  on  the  27th,  and  five  otliers  during  next  thirty-six  hours,  with  fall  of  temperature  to  97°. 
Admini.stration  of  large  doses  of  oil  of  turpentine,  one  ounce  during  the  thirty-six  hours  of  haem- 
orrhage.   Delirium  and  unconsciousness  for  nine  days.    Final  recovery.    Discharged  March  20th. 

Fig.  8. 


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86 


Temperature-chart  of  Case  of  .Vborlive  Typhoid  Fever. 


CONSIDERATIOX   OF  SPECIAL    SYMI'TOMS.  S7 

by  pallor  of  the  face  and  followed  quickly  by  intense  determination  of  blood 
to  the  head  and  by  orthopnoea. 

The  pulse  is  increased  in  frequency,  and  often  in  proportion  to  the  elevation 
of  temperature.  It  rises  in  the  evening  with  the  temperature  and  fall-  in  the 
morning,  but  besides  this  it  is  subject  to  many  variations  iVom  time  to  time, 
and  is  readilv  modified  bv  slight  influences.  Its  rate  is  trenerallv  somewhere 
between  100  and  120  per  minute.  A  velocity  above  120  indicates  a  deciiUil 
condition  of  cardiac  weakness.  It  is  not  infrequent,  however,  to  find  the  pulse 
but  little  accelerated  even  when  the  temperature  is  high.  This  occurs  more 
often  in  typhoid  fever  than  in  any  other  of  the  inl'ectious  febrile  diseases.  On 
the  other  hand,  the  pidse  may  be  unduly  frecpient  in  mild  cases  when  the 
temperature  is  but  little  elevated.  It  is  at  first  full  in  volume  and  very  ulten 
markedly  dicrotic.  This  existence  of  dicrotism  is  particularly  characteristic 
of  typhoid  fever.  As  the  disease  advances  and  weakness  grows  greater  the 
frecpiency  of  the  pulse  increases.  In  severe  cases  it  may  often  reacii  140  or 
150  a  minute,  and  recovery  yet  ensue,  though  a  rate  as  high  as  this  renders 
the  prognosis  very  grave.  At  the  same  time  it  loses  in  force  and  becomes 
compressible  and  small.  If  exhaustion  progresses,  it  becomes  yet  faster,  run- 
ning and  almost  imperceptible.  At  the  same  time  duskiness  of  the  skin  and 
coldness  of  the  extremities  indicate  the  great  weakness  of  the  circidation. 
This  local  coldness  may  exist  even  when  the  general  temperature  is  high,  and 
constitutes  a  decided  danger  signal.  Collapse  may  rapidly  develop  fn)m  this 
condition.  A  sudden  slowing  and  weakening  of  the  pulse  may  also  indicate 
a  tendencv  to  collapse.  In  a  case  to  which  reference  Mill  be  made  more  par- 
ticularly the  pulse  fell  in  a  lad  of  seventeen  years  to  28  for  a  period  of  three 
or  four  hours,  attended  with  subnormal  temperature,  95°  to  97°  F.,  and  with 
respiration  of  from  6  to  8  per  minute. 

As  the  patient  approaches  convalescence  the  pulse  diminishes  in  rapidity,  and 
after  convalescence  is  established  not  infrequently  becomes  abnormally  slow. 
This  post-tvphoid  bradycardia  need  excite  no  anxiety,  even  wIk'u.  a-  I  have 
frequently  observed,  it  continues  during  several  weeks  at  a  rate  of  50  or  45. 
Cases  are  met  with  where  the  pidse  falls  as  low  as  35.  I  have  seen  this  con- 
dition especially  in  hospital  practice  and  in  the  cases  ol"  men  of  strong,  muscu- 
lar frame  and  phlegmatic  temperament.  Exertion  will  usually  cause  a  marktHl 
rise  in  the  pulse-rate.  Indeed,  it  is  not  rare  to  find  persistent  rapidity  of  pulse 
continuing  as  the  temperature  falls,  and  even  for  some  time  alter  coiivalrs.vncv 
is  otherwrse  complete.  This  may  be  the  result  of  mere  cardiar  irritability,  or 
may  be  caused  bv  the  slow  disappearance  of  serious  lesions  of  the  cardiac  nms- 
cle.  It  occasionallv  happens  that  wlwi.  these  latt.-r  hav  b.vn  severe  the 
lieart's  action  becomes  so  rapid  an<l  feeble  on  exertion  as  to  necessitate  long- 

continued  rest  and  care. 

The  blood  shows  littl.>  alteration  in  the  early  stages  ..f  typhoid  Irvr,  l.u( 
in  the  thinl  week  a  decided  diminution  in  (ii.  number  of  re<l  blood-clls  and 
in  the  percentage  of  haemoglobin  tak.vs  place.  The  numb.-r  ..I  l..uco.-vt..s  ,s 
not  materiallv  affected,  and  this  li.t,  as  O-ler  has  point...!  .,ul,  n.ay  b..  ..I  value 


88  TYPHOID    FEVEB. 

in  distinguishing  the  disease  from  septic  and  inflammatory  processes  in  which 
leiicocytosis  occurs. 

The  respiratory  symptoms  always  demand  close  watching.  Bronchitis  is 
nearly  always  present  in  greater  or  less  degree,  and  varies  remarkably  from 
time  to  time  during  the  course  of  the  case.  Although  it  may  be  said  in  gen- 
eral, therefore,  that  the  rate  of  respiration  advances  with  that  of  the  pulse  and 
of  the  temperature,  we  must  be  prepared  for  many  variations  which  have  no 
serious  significance.  Marked  rapidity  of  breathing  may  sometimes  be  explained 
by  the  encroachment  on  the  thoracic  area  from  displacement  of  the  diaphragm, 
due  to  tympanitic  distension.  Mere  nervous  influences  may  cause  it  also,  and 
I  have  occasionally  seen  severe  paroxysms  of  dyspnoea  without  corresponding 
disturbance  of  pulse  in  cases  of  the  hysteroidal  type.  It  is  doubtless  con- 
nected in  some  cases  with  the  changes  in  the  cardiac  and  respiratory  mus- 
cles. It  is  not  rare  to  find  the  breathing  at  36  or  40  when  the  pulse  is  not 
above  85  or  95.  Great  rapidity  of  breathing  may  even  be  associated  with 
slow  pulse,  an  extreme  instance  of  which,  noted  by  Murchison,  showed  the 
respirations  without  discoverable  pulmonary  lesion  to  be  48,  while  the  pulse 
was  at  the  same  time  only  42.  Abnormal  slowness  of  respiration  is  less  com- 
mon. I  attended  in  consultation  with  Dr.  Mecray  of  Camden,  N.  J.,  a  case 
in  a  lad  of  seventeen  years,  already  referred  to,  where  at  the  tenth  day  of  a 
relapse  there  occurred  on  six  successive  days,  beginning  at  midnight  and  last- 
ing for  three  or  four  hours,  an  alarming  fall  in  the  respiration,  as  low  as  6,  7, 
or  8  in  the  minute,  and  at  the  same  time  a  drop  in  the  pulse  to  28  or  30,  and 
in  the  temperature  to  97°  and  even  to  95|°  F.  Death  was  imminently  impend- 
ing, and  was  averted  only  by  colossal  doses  of  strychnine. 

Analyses  of  the  expired  air  have  revealed  nothing  of  importance  save  the 
presence  of  ammonia  in  the  later  stages  of  some  cases. 

Auscultation  may  reveal  scattered  bronchial  rales  from  the  onset  of  the 
case ;  indeed,  the  physical  signs  of  bronchitis  may  be  so  marked  as  to  divert 
attention  from  the  constitutional  nature  of  the  disease.  As  a  rule,  however, 
they  increase  as  the  fever  advances.  In  the  second  week  and  later  harshness 
of  respiratory  murmur  and  sonorous,  sibilant,  and  mucous  rales  may  be  ex- 
pected, especially  at  the  base  posteriorly.  Not  rarely  on  turning  the  patient 
on  his  side  or  raising  him  to  a  sitting  posture  there  will  be  heard  in  this  region 
a  fine,  dry,  crepitant  expansion  rale.  This  will  disappear  after  a  few  breaths, 
dispelling  the  momentary  fear  of  incipient  pneumonia.  Percussion  resonance 
may  be  impaired  slightly  over  the  base,  owing  to  imperfect  expansion;  but 
distinct  dulness  appears  only  in  case  of  pneumonia  or  pleurisy.  Bronchial 
catarrh  and  pulmonary  congestion  become  so  extensive  and  severe  in  some 
cases  of  severe  adynamic  type,  and  prove  so  obstinate,  that  in  view  of  the 
attending  irregular  fever  the  fear  of  developing  tuberculosis  may  be  enter- 
tained. Cough  is  a  very  irregular  symptom.  It  is  sometimes  severe  and 
harassing  in  the  early  stages,  but  later  may  be  comparatively  slight,  even 
when  examination  of  the  chest  shows  marked  catarrh  and  congestion. 

The  urine  is  usually  diminished  in  quantity,  high-colored,  and  of  increased 


COMPLICATIONS  AND   SEQUEL.^.  89 

specific  gravity  in  the  earlier  stages  of  the  disease.  Tlie  (liininution  luav  per- 
sist until  convalescence,  or  the  urine  may  become  liglit-coloretl  and  be  excreteil 
in  larger  quantities  about  the  end  of  the  second  week.  As  wnvalescenee  is 
more  nearly  approached,  and  during  it,  the  specific  gravity  falls  very  consid- 
erably, the  reaction  is  feebly  acid  or  is  alkaline,  and  a  (juantity  of  urine 
decidedly  greater  than  normal  is  passed.  The  amount  of  urea  excretetl  is 
increased  in  the  early  stages,  and  often  throughout  the  attark.  It  is  not 
affected  by  the  existence  of  diarrhoea,  but  may  be  reduced  by  the  occurrence 
of  an  inflammatory  complication.  It  is  frequently  diminishetl  during  eonva- 
lescence.  Uric  acid  is  increased  while  the  attack  is  in  progress,  but  diminishetl 
during  convalescence,  while  the  reverse  is  true  of  the  chlorides.  A  febrile 
albuminuria  is  very  common,  and,  as  will  be  seen  later,  the  complication  of 
infectious  nephritis  is  not  rare.  The  diazo-reaction  described  by  Ehrlich 
depends  upon  the  existence  in  the  urine  in  typhoid  fever  of  certain  aromatic 
bodies  which  are  capable  of  producing  definite  color  reactions  with  the  diazo- 
compounds.  Ehrlich  considered  the  reaction  characteristic  of  typhoid  fever. 
It  is  true  that  it  is  very  connuonly  present  in  this  disease,  but  it  may  also  fre- 
quently be  observed  in  tubercular  meningitis  and  in  some  other  conditions. 
It  is,  for  examj)le,  rarely  absent  in  measles.  To  employ  the  test  two  solutions 
are  kept — one  a  J  per  cent,  solution  of  sodium  nitrite,  the  other  a  \  jier  cent, 
solution  of  hydrochloric  acid  saturated  with  sulplianilic  acid.  Just  before 
using,  40  parts  of  the  first  are  mixed  with  1  part  of  the  second.  The  hvdro- 
chloric  acid  acts  upon  the  sodium  nitrite  and  liberates  nascent  nitrous  acid, 
and  this,  acting  upon  the  sulphanilic  acid,  produces  diazo-benzene-sulphonic 
acid.  Equal  parts  of  the  mixture  of  the  two  solutions  and  of  urine  are  now 
thoroughly  shaken  in  a  test-tube  and  overlaid  with  ammonia.  If  the  reaction 
develops,  a  deep-red  ring  forms  at  the  junction.  The  color  varies  from  a  car- 
mine to  a  deep  garnet.  In  normal  urine  the  ring  which  forms  has  no  tinge 
of  red. 

In  very  severe  cases  of  typhoid  fever,  with  unconsciousness,  the  urine  is 
])assed  involuntarily.  Retention  of  urine  is  often  an  early  sym]>tom  and 
demands  catheterization.  As  soon  as  marked  hebetude  apjx'ars  the  region  t)f 
the  bladder  should  be  percussed  daily,  as  ])artial  retention  may  occur  even 
when  there  is  occasional  discharge  from  overflow. 

Complications  and  Sequelae. — Many  of  the  conditions  already  descrilxHl 
as  symptoms  or  as  pathological  lesions  might  with  efpial  propriety  be  considered 
among  the  very  numerous  and  varied  complications  and  sequels  (tf  the  disease. 

Of  the  complications  involving  the  dermal,  nuiscular,  and  osseous  systems, 
bed-sores  deserve  first  mention,  as  they  arc  frc(|ucnt  and  troublesome  in 
severe  cases.  They  depend  u])<)n  the  im|)erfect  niMriti(»ii  of  fhc  skin,  (he 
emaciation,  the  constant  pressure  over  bony  prominences,  ami.  in  (he  case  of 
the  nates,  the  great  diflicidty  in  keeping  the  |)arfs  perfectly  clean  and  dry. 
Patients  may  die  from  the  exhaustion  caiise<l  i)y  bed-sores  aft«'r  having;  sur- 
vived the  fever.  The  only  way  to  avoid  them  is  by  daily  eareliil  examination 
of  all  dependent  parts  and  by  the  prompt  adoption  of  preventive  measures. 


90  TYPHOID    FEVER. 

Atrophic  lines  (lineje  albicantes)  may  develop  in  the  skin  during  convalescence, 
especial Iv  in  children  and  young  adults.  I  agree  with  Bouchard  that  they  are, 
at  least  usually,  the  result  of  stretching  due  to  the  rapid  growth  after  the  fever 
has  ceased.  A  very  similar  condition  was  described  by  Wilkes  as  atrophic  in 
nature.  Not  infrequently  abscesses  of  the  skin,  subcutaneous  tissue,  or  mus- 
cles form. 

Herpes  labialis  is  conspicuous  by  its  absence.  Its  presence,  in  fact,  offers 
a  strong  presumption  against  the  diagnosis  of  typhoid  fever.  It  is  to  be  borne 
in  mind,  however,  that  it  may  sometimes  occur  in  this  disease,  though  with 
nothing  like  the  frequency  with  which  it  occurs  in  pneumonia,  malaria,  and 
cerebro-spinal  fev^er. 

Temporarv  falling  of  the  hair  is  a  very  common  sequel,  but  permanent 
baldness  is  rare.  The  new  hair  often  lacks  lustre  at  first.  It  occasionally 
happens  that  curly  hair  has  grown  in  cases  in  which  it  was  previously  straight, 
but  this  condition  need  not  be  permanent. 

The  nails  often  exhibit  transverse  markings  after  recovery,  indicating  the 
impairment  of  nutrition  which  existed  during  the  attack. 

Rupture  of  muscles,  often  followed  by  haemorrhage  into  them,  occasionally 
happens. 

Periostitis  of  different  bones,  but  especially  of  the  tibia,  is  an  occasional 
sequel.  It  may  subside  or  may  go  on  to  necrosis.  Keen  has  collected  the 
records  of  37  cases  of  necrosis  of  the  tibia  following  typhoid  fever.  In  a 
series  of  cases  I  have  observed  obstinate  periostitis  of  the  sternum  or  of  the 
crests  of  the  ilia,  or  in  two  instances,  judging  from  the  location  of  the  pain  and 
from  the  effect  of  movement  of  the  trunk,  of  the  front  of  the  spinal  column. 
Swelling  and  even  suppuration  of  the  joints  are  sometimes  seen. 

A  tendency  to  grow  stout,  temporarily  or  permanently,  is  a  not  infrequent 
sequel  to  typhoid  fever.  On  the  other  hand,  patients  may  remain  permanently 
leaner  than  before,  and  never  regain  robust  strength, 

Meninjritis  and  cerebral  haemorrhage  have  alreadv  been  referred  to  in  the 
remarks  on  Morbid  Anatomy  as  rare  complications.  It  is  essential  to  appre- 
ciate, however,  that  the  nervous  symptoms  of  typhoid  fever,  though  they  may 
be  very  grave,  are  seldom  connected  with  any  actual  organic  lesions  of  the  mem- 
branes or  substance  of  the  nerve-centres.  When  meningitis  does  occur,  it  may 
result  from  suppuration  in  the  temporal  bone,  or  it  may  be  pysemic  or  tubercu- 
lous in  nature.  It  is  not  to  be  denied  also  that  in  rare  instances  a  certain 
degree  of  meningitis  is  set  up  as  a  part  of  the  special  typhoid  lesions.  The 
nutrition  of  the  brain  and  cord  often  suffers  severely,  however,  from  the  pro- 
longed fever,  systemic  infection,  and  sustained  reflex  irritation  from  the  local 
lesions. 

Mental  defects,  varying  from  mere  impairment  of  intellect  to  a  high  grade 
of  confusional  insanity,  may  appear  during  convalescence.  At  times  the 
patient  emerges  from  the  fever  with  mental  weakness  and  poor  memory, 
which  persist  for  weeks  or  even  for  months.  Or,  again,  when  convalescence 
seems  to  be  advancing  normally  a  true  post-typhoid  insanity  develops.     There 


\ 


COMPLICATIONS  AXn    SEi^CKL.l^:.  ill 

are  confusion  of  ideas  and  inability  to  recognize  friends  or  familiar  sitrhts. 
Hallucinations  are  not  rare,  and  mild  or  even  maniacal  delirium  may  occur. 
In  the  great  majority  of  cases  recovery  follows,  though  the  symptoms  may  l»r 
alarming  and  obstinate. 

Slowness  of  speech  is  at  times  present  after  typh(«iil  fever,  and  temjiorary 
aphasia  may  occur,  especially  in  young  children.  In  rare  instances  1  have 
known  epileptic  convulsions  to  follow,  and  hystero-epilepsv  has  also  been 
reported  as  a  sequel. 

The  organs  of  special  sense  sometimes  exhibit  alterations.  Otorriid'a  is  nut 
infrequent,  especially  in  children.  Sloughing  of  the  cornea  may  rarely  occur, 
especially  if  coma  vigil  exist.  Temporary  blindness  not  depending  upon  this 
has  been  observed. 

Neuralgias  and  hyperesthesias  of  any  kind  are  not  common  sequels. 

Paralysis  of  different  forms  is  seen  as  a  complication  or  sequel.  It  gener- 
ally does  not  develop  until  several  weeks  after  convalescence  begins,  although 
it  sometimes  comes  on  during  the  height  of  the  disease  or  even  at  its  com- 
mencement. It  usually  depends  on  a  neuritis,  and  almost  any  nerve  may 
be  attacked.  The  paralysis  may  be  limited  to  a  single  nerve,  or  it  may 
assume  a  paraplegic  or  even  hemiplegic  form.  Recovery  generally  ensues 
after  weeks  or  months.  Some  of  these  cases  may  be  due  to  a  poliomyelitis, 
or  a  sudden  hemiplegia  may  possibly  in  some  instances  be  the  result  of  a 
thrombosis  or  an  embolism. 

Muscular  tremor  and  chorea  are  occasional  sequels. 

Among  the  complications  of  the  digestive  system  may  sometimes  be  observi-d 
ulceration  of  the  tongue  and  of  the  mucous  membrane  of  the  cheeks.  Cancrum 
oris  has  been  reported  in  a  few  cases,  and  aphthous  stomatitis  also,  although  it 
is  rare  and  is  seen  only  in  very  debilitated  conditions  or  in  patients  treated  in 
unhygienic  surround inss.  Alveolar  abscess  is  liable  to  develop.  Diphtheritic 
inflammation  of  the  pharynx  and  asojihagus  is  a  dangerous  conq)lication  not 
rarely  met  with.  Dysphagia  may  be  due  to  this,  to  a  paresis  of  the  musi-les 
of  deglutition,  to  a  cellulitis  of  the  neck,  or,  especially  in  children,  to  |)h:iryn- 
geal  hyperesthesia. 

Parotitis,  usually  unilateral  and  suppurative,  is  an  occasional  and  danger- 
ous complication.  It  generally  begins  during  the  third  or  iburth  week,  and  is 
seen,  as  a  rule,  only  in  severe  cases.  Both  glands  may  be  involvr.j  at  once,  ..r 
first  one  and  then  the  other.  Suppuration  is  very  apt  to  o<vur.  in  whi.h 
respect  this  secondary  form  of  parotitis  differs  widely  from  nnnnps.  F.iebei- 
meister  states  that  parotitis  has  become  much  less  common  since  the  intn.(liic- 
tion  of  antipyretic  methods. 

Profuse  gastric  hemorrhage,  which  may  terminate  fatally,  has  been  ob>erved, 
as  in  a  case  reported  bv  Weiss.  I)o.d,tless  in  this  ease  the  haMuorrhage  wa< 
caused  by  gastric  ulcer.  Care  must  be  taken  not  to  ..onhmnd  with  tln^  the 
vomiting  of  blood  which  has  flowed  down  IVnin  the  pu.frior  naiv>.  On 
several  occasions  I  have  been  greatly  alarmed  until  the  sou.v.  ..I  the  haMuo,- 
rhatre  was  discovered. 


92  TYPHOID    FEVER. 

Dysentery,  sometimes  diphtheritic,  occasionally  exists  as  a  complication  or 
sequel.     Gangrene  of  the  intestinal  mucous  membrane  may  even  take  place. 

Jaundice  only  rarely  complicates  typhoid  fever.  It  may  result  from  a 
catarrhal  process  or  from  parenchymatous  changes  in  the  liver  which  can 
attain  such  a  degree  that  the  characteristic  symptoms  of  acute  yellow  atrophy 
api)ear.  The  liver  is  occasionally  enlarged.  Hepatic  abscess  is  a  rare  sequel. 
Diphtlieritic  or  ulcerative  processes  may  occur  in  the  gall-bladder. 

Perforation  of  the  intestine  by  an  ulceivis  the  most  dangerous  complication 
which  can  arise.  It  occurs  in  about  2  to  3  per  cent,  of  all  cases.  The  4680 
cases  tabulated  bv  Fitz  give  a  mortality  from  perforation  somewhat  higher 
than  this — viz,  6.58  per  cent.  The  accident  forms,  according  to  Murchison, 
about  11  per  cent,  of  the  causes  of  death  in  typhoid  fever.  In  the  2000 
Munich  autopsies  perforation  constituted  5.7  per  cent,  of  the  causes  of  death. 
It  is  very  frequently  preceded  by  haemorrhage.  It  takes  place  most  often  in 
the  severer  cases,  especially  in  those  in  which  other  abdominal  symptoms,  as 
diarrhoea  and  tympanites,  have  been  marked.  At  the  same  time,  must  ever 
be  borne  in  mind  the  important  fact  that  it  sometimes  occurs  in  the  mildest 
of  cases  which  have  exhibited  no  abdominal  symptoms.  Fitz  found  it  much 
more  frequent  in  men  than  in  women,  and  rarer  in  children  than  in  adult  life. 
It  is  commonest  toward  the  end  of  the  second  week  and  in  the  third  and  fourth 
weeks,  but  it  may  occur  later  than  this,  and  it  has  been  met  with  as  early  as  the 
eio-hth  day.  There  are  numerous  instances  on  record  in  which  perforation  has 
taken  place  some  weeks  after  convalescence  had  commenced,  the  patients  being 
out  of  bed  and  even  at  work.  Among  the  immediate  causes  of  the  accident 
may  be  mentioned  the  presence  of  hardened  fsecal  masses,  undigested  food, 
excessive  tympanites,  severe  vomiting,  the  increased  peristalsis  caused  by 
purgative  medicines  or  by  an  enema,  ascarides,  straining  at  stool,  sudden  changes 
in  position.  A  perforation  which  occurs  early  in  the  attack  is  probabl}^  due  to 
the  separation  of  a  slough,  while  that  which  comes  later  is  probably  the  result 
of  an  extension  of  the  ulcerative  process  to  the  visceral  peritoneum.  The 
opening  through  the  intestine  is  generally  small,  with  clean-cut  edges,  and  the 
slough  may  still  be  present  and  cover  it,  or  may  have  entirely  disappeared. 
The  symjitoms  attending  perforation  come  on  abruptly.  They  consist  of  very 
severe  abdominal  pain,  which  develops  in  the  right  iliac  fossa  and  rapidly 
spreads  over  the  whole  abdomen,  and  of  profound  colla})se,  the  latter  evidenced 
by  feeble  running  pulse,  cold  sweat,  subnormal  temperature,  feeble  respiration, 
great  thirst,  suppression  of  urine,  and  frequent  vomiting.  Death  may  take 
place  in  a  few  hours.  If  it  does  not,  the  symptoms  of  acute  diffuse  peritonitis 
soon  set  in,  the  abdomen  becoming  more  tympanitic  and  the  liver  dulness  being 
obliterated.  The  latter  symptom  constitutes  a  valuable  diagnostic  sign.  The 
abdomen  grows  excessively  tender,  the  face  wears  an  expression  of  intense  suf- 
fering, the  legs  are  drawn  up,  and  the  temperature  rises  again.  Death  takes 
place  in  two  to  four  days,  or  sometimes  after  a  longer  time. 

The  opinion  was  formerly  held  that  perforation  was  inevitably  fatal,  but 
there  is  abundant  evidence  that  recovery  mav  occur  in  rare  instances.     Thus 


COMPLICATIOXS    AXD    .SEQl'EL.H:.  93 


the  perforation  may  at  times  produce  only  a  looalizwl  peritonitis,  terminating 
in  abscess,  which  may  be  discliarged  by  tlie  bowel  or  externallv,  ami  recovery 
follow;  or  the  bowel  at  the  seat  of  a  minute  perforation  may  be  so  tirmlv 
glued  by  an  adhesive  inflammation  to  the  wall  of  the  abdomen  (.r  to  another 
loop  of  intestine  that  little  or  no  escape  of  intestinal  contents  can  take  place 

Peritonitis,  local  or  diffuse,  resulting  from  ciuises  other  than  perforation, 
may  complicate  typhoid  fever.  This  may  bo  produced  by  the  spreading  of 
inflammation  from  the  ulcerating  mucous  lining  to  the  serous  laver  of  the 
intestine,  without  perforation  existing ;  or  it  may  be  the  result  of  the  rnj>tin-o 
of  a  softened  mesenteric  gland  or  of  the  bursting  into  the  peritoneum  of  an 
abscess  of  the  spleen,  liver,  gall-bladder,  urinary  bladder,  or  abdominal  wall  ; 
or  it  may  follow  causes  entirely  independent  of  the  febrile  disease.  I  have 
known  death  to  occur  from  general  peritonitis,  with  abundant  ])urulent  and 
plastic  exudation,  as  early  as  the  tenth  day,  without  perforation  and  without 
any  evidence  to  connect  its  origin  with  any  particular  ulcer  in  the  intestine. 

Venous  thrombosis  is  the  most  frequent  ct)mplication  from  the  side  of  the 
circulatory  system.  It  is  oftenest  met  with  in  the  femoral  vein,  where  it  is 
of  very  common  occurrence,  producing  cedema  and  ]>ain.  Tt  happens  nuich 
oftener  in  the  left  leg  than  in  the  right,  possibly  due  to  the  tact  that  the  left 
iliac  vein  is  crossed  and  pressed  upon  by  the  right  iliac  artery  ;  not  rarely  the 
other  leg  is  subsequently  affected.  It  may  be  a  complication,  but  is  oftener  a 
sequel,  coming  on  after  convalescence  seems  established.  Its  onset  is  marked 
by  pain  in  the  groin  or  thigh  or  calf.  There  is  tenderness  on  pressure  along 
the  femoral  vein,  which  can  soon  be  felt  to  be  swollen  or  hard.  Pain  is  also 
complained  of  if  pressure  be  made  upon  the  calf  The  swelling  of  the  log 
which  follows  is  often  considerable,  and  is  more  elastic  and  pits  loss  readily 
than  in  ordinary  oedema.  It  indicates  that  the  lymph-channels,  as  well  as  the 
vein,  are  involved.  The  leg  is  heavy  and  entirely  powerless.  Irregular  fever 
of  moderate  grade  is  kept  up  for  some  days,  and  may  at  fn-st  cause  appreluMi- 
sion  of  a  relapse.  Recovery  nearly  always  takes  i)laee,  owing  to  the  late 
])eriod  in  the  case  when  this  sequel  occurs.  Convalescence  is,  however,  pro- 
tracted ;  the  swelling  subsides  gradually  as  the  collateral  circidation  is  estab- 
lished, but  some  slight  enlargement  (»f  the  afl'eeted  leg  may  remain  pcr- 
manentlv.  In  very  rare  instances  the  thrombus  may  become  dislodgetl  and 
be  carried  to  the  heart  with  fatal  result,  or  septicaemia  may  ensue  upon  suppu- 
rative softening  of  the  clot. 

Obliteration  of  the  larger  or  smaller  arteries  by  embolism  or  throiubosis  is 
an  infrequent  complication.  Gangrene  of  the  part  from  wliieh  the  blood  is 
cut  off  naturally  follows.  Arteries  sui)plying  any  of  ilw  skclrtnl  or  vis<-eral 
pcn-tions  of  the' body  may  be  involved,  but  the  femoral  artery  i>  the  ..ne  in 
which  the  condition   most  frequently  develops. 

Pericarditis  and  endocarditis  arc  unusual  eomplicalions,  while  myoeardiiis, 
with  consequent  dilatation  of  the  cavities,  is  more  frecpient.  Valvular  dis<.ase 
is  a  rare  sequel.  Graves'  disease;  has  also  Ixrn  known  to  develop.  A  post- 
tvphoid  anaemia  is  occasionally  observed,  and  tl..'  di.uinnlion  ofthe  pereeuiage 


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COMPLICATIONS   AXD    SEQVEL.T:.  95 

of  red  blood-cells  and  of  lisemoglobin  may  be  very  great.  Ollivier  reports 
the  development  of  chlorosis  as  among  the  sequels.  The  disease  may  be 
complicated  by  the  hsemorrhagic  diathesis,  though  this  tendency  to  bU-ed  may 
exist  only  under  the  influence  of  and  din-iug  the  disease.  This  condition  is 
not  very  rare,  and  the  haemorrhage  may  occur  as  petcchijc  or  as  excessive  cpis- 
taxis,  or  may  take  place  from  the  gums,  .the  stomach,  or  the  kidnevs. 

Spontaneous  rupture  of  the  spleen  is  a  very  rare  complication  of  tvphuid 
fever.  A  more  common,  tljough  still  unusual,  accident  is  the  softcnimr  and 
rupture  of  a  splenic  infarct.  Mention  has  already  been  made  of  the  great 
enlargement  of  the  mesenteric  glands  which  sometimes  takes  place,  and  may 
lead  to  abscess.     The  other  lymphatic  glands  are  rarely  involved. 

In  the  domain  of  the  respiratory  system  it  may  be  noted  that,  although 
redness  and  s\velling  of  the  nasal  mucous  membrane  are  common  during  the 
disease,  ooryza  is  a  rare  sequel.  Necrosis  of  the  cartilages  ol'  the  nose  is  also 
occasionally,  but  rarely,  observed. 

Laryngitis  sometimes  exists  either  as  a  complication  or  as  a  sequel.  Laryn- 
geal ulceration  or  perichondritis  may  develop,  though  this  is  generally  con- 
sidered rare.  Qildema  of  the  glottis  is  apt  to  be  produced  bv  the  laryngeal 
implication,  though  it  may  occur  independently  of  it.  Holscher  reports  trache- 
otomy done  15  times  for  perichondritis  in  2000  fatal  cases  of  typhoid  fever. 

Bronchitis  has  been  described  among  the  symptoms.  Both  lobidar  pneu- 
monia and  collapse  of  portions  of  the  lung  may  be  consecutive  to  it. 

Lobar  pneumonia  is  a  common  complication.  It  occasionally  develops 
early,  even  as  an  initial  symptom,  and  in  silch  cases  the  diagnosis  of  primary 
pneumonia  might  easily  be  wrongly  made.  (See  Varieties  of  Typhoid  Fever.) 
Much  more  frequently  pneumonia  develops  in  the  second  or  third  week,  or 
even  after  convalescence  has  commenced.  It  is  generally  unattended  by  rusty 
expectoration  or  increase  of  cough,  and  may  readily  be  overlooked.  The  tem- 
perature curve  is  apt  to  be  highly  irregular.  In  a  fatal  case  which  I  saw  in 
consultation  with  Dr.  W.  H.  Warder,  where  i>neumonia  occiwred  from  expo- 
sure in  early  convalescence,  the  temperature  gradually  rose  I'or  several  days, 
and  then  assumed  a  paroxysmal  type,  with  morning  fall  to  9il°  and  evening 
rise  to  106°   for  three  days  before  death. 

Pulmonary  oedema  and  hypostatic  congestion  of  the  lung\s  an-  ol  very  Irc- 
(pient  occurrence  in  the  later  stages  of  the  disease.  They  rcsidt  from  lailure 
of  the  circulation  and  the  constant  reciunbent  position  of  the  j)a(ient.  \hvu\- 
orrhagic  infarct  sometimes  develops,  and  gangrene  or  abscess  may  result  from 
this  or  from  lobular  or  lobar  ])neumonia. 

Pleurisy  with  effusion  is  a  serious  but   rather  rar vurrence.     When  it 

arises  acutelv  during  the  course  of  (he  disease  it  may  !.<■  sero-pla>ti<- and  ter- 
minate in  gra<lual  abs()ri)tion,  but  when  it  d.'velops  ^lowly  as  a  .^cpicl  it  is 
nearly  always  purulent.  The  acc.Mupauying  chart  (see  Fig.  7)  of  th.-  lem- 
l)erature  in"' the  case  referred  to  on  page  6(J  is  interesting  as  dlustral.ng  the 
extreme  irregularities  introduced  by  the  occurren.-e  of  serious  compb.-ations. 
Pneumothorax   is  a  rare  con.plication,  au<l   I.M"m..ptysis  i.n  occas.ouMJIv  scc-n. 


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COMPLICATIONS   AND    SEQUEL.^.  97 

Acute  railiarv  tuborcnlosis  niav  bo  developed  during  or  after  tvphoid  fever. 
This,  however,  must  be  of  extremely  rare  occurrence,  and  it  is  not  improbable 
that  some  of  the  reported  cases  were  errors  of  diaijnosis  by  which  tuberculosis 
was  regarded  as  typhoid.  The  general  opinion  that  persons  recovering  from 
typhoid  are  particularly  liable  to  develop  phthisis  tlucs  not  seem  sui)p()rttHl  by 
adequate  evidence. 

Febrile  albuminuria  without  casts  is  common  in  typhoid,  as  already  stated, 
and  does  not  materially  add  to  the  gravity  of  the  case.  Acute  nephritis  may 
develop,  however,  at  the  beginning  or  during  the  course  of  the  disease,  when 
the  urine  becomes  scanty  and  contains  albumin,  casts,  epithelium,  or  bl(K)d. 
The  affection  is  a  severe  one,  and  the  i)atient  may  die  of  uraemia,  l^ndoubt- 
edly,  the  typical  typhoid  state  is  often  induced  in  part  by  this  renal  com- 
plication. The  nephritis  which  comes  on  as  a  sequel  after  convalescence 
has  commenced  is  attended  by  oedema  and  the  usual  symptoms  of  acute 
Bright's  disease.  It  is  often  followed  by  recovery.  Sugar  in  minute  amount 
is  occasionally  found  in  the  urine  during  the  course  of  the  fever,  and  diabetes 
apparently  occurs  as  a  rare  sequel.  Hanuaturia  is  a  rare  complication,  and 
indicates  a  dangerous  hsemorrhao-ic  tendencv. 

Vesical  catarrh  is  not  infre<]uent,  especially  after  cases  where  retention  of 
urine  was  present  and  required  catheterization.  It  may  be  slight  or  severe, 
transitory  or  obstinate  and  troublesome.  More  rarely  pyelitis  follows  tyj)hoid 
fever,  and  may  even  be  attended  with  ulceration  and  membranous  exudation. 
Among  other  rare  sequels  may  be  mentioned  orchitis,  inflaniiiKitioii  of  the 
ovaries,  and  gangrene  of  the  genitals,  which  latter  may  occur  in   both  sexes. 

Menstruation  is  often  irregular  during  the  attack.  It  may  occtu-  prema- 
turely and  be  profuse,  or  it  may  fail  to  appear.  Amenorrhoea,  lasting  several 
months,  is  a  frequent  sequel. 

Pregnancy  may  possibly  give  some  degree  of  immunity  from  typhoid  fever, 
but  does  not  protect  absolutely,  as  was  formerly  supjiosed.  Abortion  is  very 
apt  to  take  place,  especially  if  the  disease  be  contracted  in  the  first  half  of 
pregnancy.     It  occurs  oftenest  during  the  later  periods  of  the  disease. 

The  existence  of  typhoid  fever  does  not  protect  the  system  fi-om  possible 
invasion  by  other  infections.  Erysipelas  may  develop  during  the  height  of 
the  disease,  or  more  frequently  as  a  sequel,  but  its  occurrence  is  rare.  Scar- 
latina has  been  repeatedly  observed  in  those  suffering  with  tyjihoid  fever,  and 
there  are  other  reported  instances  in  which  the  reverse  has  oeeurre<l.  in  fact, 
Murchison  believes  that  scarlatina  predisposes  to  the  <levelo|)iiieiit  of  (yphoid 
fever.  It  must  not  be  forgotten  that  an  erythema  m.iy  :iit|)<:ir  early  in  typhoid 
and  lead  to  error  in  diagnosis.  Rubeola,  variola,  vaeeinia,  inllnen/a,  typhus 
fever,  and  pertussis  may  present  themselves  in  coml)iiia(ion  with  ly|.hoid  fever. 
Karlinsky  reports  a  case  complicated  l)y  anthrax.  Diphtheria  has  been  re- 
peatedly observed   in  combination  with  tyi)lioi<l  f<'ver,  espeeially  in  eluldren. 

Malarial-iyphoid  (Tifpho-rna/arla/)  Frrrr.—TUr  f<Tin  "  I  vpho-malMrial 
fever,"  first  proposed  by  Woodward,  is  misleading  and  should  he  al)au.loii<-<l. 
It  has  been  forced  to  designate  two  distinct  classes  of  diseases,  to  neither  of 

Vol..  I.— 7 


98,  TYPHOID    FEVER. 

which  it  is  strictly  appropriate.  The  first  class  consists  of  cases  of  severe  mala- 
rial fever  of  the  remittent  type,  in  whicih  the  patient  passes  into  a  typhoid  state. 
To  these  cases  the  term  "  typhoid  remittent  "  is  properly  applicable,  just  as  we 
say  typhoid  pneumonia  or  typhoid  dysentery  in  the  corresponding  form  of 
these  diseases.  The  second  class  is  a  true  combination  in  the  system  of  the 
poisons  of  malarial  and  typhoid  fevers,  and  this  type  of  disease  can  be  cor- 
rectly stvled  "  malarial  typhoid."  There  is  abundant  evidence,  both  clinical 
and  pathological,  to  show  that  this  combination  of  the  two  diseases  can  exist, 
although  it  is  doubtless  true  that  most  of  the  reported  cases  of  so-called  typho- 
malarial  fever,  bilious  remittent  fever,  mountain  fever,  etc.  were  either  purely 
malarial  or  purely  typhoid  in  nature,  but  with  some  anomalous  features,  such 
as  have  already  been  described. 

The  symptoms  of  the  combination  of  malarial  and  typhoid  fevers  are  vari- 
able, depending  upon  which  disease  predominates.  The  attack  is  apt  to  begin 
as  an  intermittent  fever,  the  paroxysms  constantly  growing  more  intense  and 
prolonged,  and  the  fever  thus  gradually  a})proaching  a  continuous  type.  The 
remissions  or  intermissions  are  great,  sudden,  irregular,  and  attended  by  pro- 
fuse sweating  and  decided  adynamia.  The  evening  elevations  of  temperature 
are  more  pronounced  than  in  ordinary  typhoid  fever,  and  the  headache  is 
apt  to  be  intense,  while  hebetude  and  delirium  are  usually  less  marked. 
Gastric  and  hepatic  derangements  are  common,  and  there  is  painful  enlarge- 
ment of  the  liver  and  spleen.  Quinine  has  no  specific  effect  upon  the  disease. 
Microscopic  examination  of  the  blood  should  show  the  presence  of  the  malarial 
organisms. 

Varieties  of  Typhoid  Fever. — Typhoid  fever  may  exhibit  variations 
either  in  its  mode  of  onset  or  in  the  fully-developed  disease.  These  may  con- 
sist in  the  exaggeration  of  certain  symptoms,  or  in  a  tendency  to  involvement 
of  certain  organs  to  an  unusual  degree,  or  in  peculiarities  in  the  general  cha- 
racter or  severity  of  the  disease  as  a  whole.  The  disorder  is  so  complex  that 
very  many  forms  have  been  described.  There  may,  in  the  first  place,  be 
decided  variations  in  the  mode  of  attack. 

In  the  onaet  with  marked  nervous  symptoms  headache  may  early  be  exceed- 
ingly severe  and  resist  all  treatment.  In  some  cases  this  is  combined  with 
.stiffness  of  the  neck,  retraction  of  the  head,  photophobia,  muscular  twitching 
or  even  convulsions;  and  under  such  circumstances  the  disease  is  likely  to  be 
mistaken  for  meningitis. 

In  the  onset  with  marked  pulmonart/  symptoms  bronchitis  may  be  the  first 
.symptom  noticed,  and  for  several  days  the  case  may  be  regarded  simply  as  one 
of  severe  bronchial  catarrh.  Occasionally  the  disease  begins  Avith  chill  and 
the  symptoms  of  croupous  j)ueumonia,  and  there  may  be  nothing  which  justi- 
fies the  diagnosis  of  any  other  disease  than  this  until  after  a  week  or  more, 
when  the  faihn-e  of  the  crisis  to  occur,  the  development  of  rose-colored  spots 
and  of  intestinal  symptoms,  and  the  general  tyj)hoid  condition  of  the  patient  may 
show  that  the  pneumonia  was  but  an  early  com])lication  of  a  general  infectious 
disease.     In  some  cases,  indeed,  it  may  remain  throughout  impossible  to  deter- 


VARIETIEH    OF    TYPHOID    FEVER.  99 

mine  whether  we  have  to  do  with  a  typhoid  jnieumonia — /.  e.  with  a  pneu- 
monia with  typhoid  symptoms— or  with  a  true  typhoid  fever  with  initial  and 
predominating  pneumonic  symptoms  and  localization. 

Much  less  frequently  similar  doubt  may  be  caused  by  the  earlv  and  intense 
development  of  pleurisy  at  the  onset  of  typhoid  fever.  The  terms  "i)neumo- 
tyi)hoid  "  and  "  pleuro-tyi)hoid  "  have  been  used  to  indicate  such  cases,  and 
the  name  "  laryngo-typhoid  "  is  given  by  Schuster  to  the  even  more  rare  cases 
where  the  onset  of  tyjihoid  fever  is  masked  by  the  great  jiromincnce  of  an 
initial  laryngeal  complication.  The  advantage  of  these  special  terms  seems 
very  doubtful. 

In  the  onset  with  marked  gastro-intestinal  symptoms  vomiting  and  diarrhrea 
may  occur  so  early  and  be  so  resistant  to  treatment  that  the  disease  simulates 
corrosive  poisoning.  Chomel,  indeed,  must  have  met  with  epidemics  j)resent- 
ing  a  large  proportion  of  such  cases,  since  he  claimed  that  this  was  the  most 
frequent  mode  of  attack.  In  some  instances  jaundice  has  also  been  present, 
and  such  cases  are  not  rarely  regarded  as  bilious  remittent  fever. 

In  the  onset  ivith  marked  renal  symptoms  the  condition  of  the  urine  and  the 
other  symptoms  at  first  so  closely  resemble  tiiose  of  acute  Bright's  disease  that 
there  may. even  be  danger  of  regarding  these  cases  as  instances  of  primary 
nephritis. 

This  early  prominence  of  certain  symptoms  may  disajipoar  soon,  or  mav 
continue  into  the  fully-developed  attack,  thus  determining  tiie  later  type  of  the 
disease  also. 

Apart  from  the  early  predominance  of  one  class  of  symptoms,  variation  of 
the  whole  course  of  the  disease  may  constitute  certain  definite  forms. 

In  the  abortive  form  the  attack  begins  often  rather  suddenly  with  chilliness. 
By  the  third  or  fourth  day  the  temjierature  reaches  103°  to  104°  F.  All  the 
characteristic  evidences  of  the  disease  are  present :  the  s])leen  is  enlarged  and 
the  gastric  symptoms  are  often  well  marked.  Tn  my  ow  n  experience  diarrhnea 
and  tympanites  are  less  pronounced.  The  rose  spots  may  develoj)  early, 
even  by  the  second  to  the  fifth  day,  but  it  is  always  to  be  considered  whether 
several  davs  of  unobserved  indisjwsition  have  not  preceded  the  apjiarcnt  onset. 
Between  the  seventh  and  the  fourteenth  days  all  the  symptoms  rapidly 
improve.  The  temperature  falls  by  rapid  lysis,  or  a  genuine  crisis  with 
copious  perspiration  may  occur.  (See  Fig.  8.)  Convalescence  is  rapid. 
According  to  Ciiantemesse,  fresh  crops  of  eruption  may  develop  even  after 
the  fall  of  temperature,  indicating  that,  although  the  fi'ver  has  gone,  the 
infectious  process  is  not  necessarily  ended,  so  that  watchful  and  ligld  earc 
should  be  enforced  for  some  time  longer. 

It  is  obvious  tliat  the  diagnosis  of  such  attacks  nuist  rest  chiefly  on  the 
detection  of  the  characteristic  eruption.  No  good  rcas<Mi  M|)peMrs  wliy  the 
abortive  form  shouhl  be  less  frequent  in  this  country  than  eiscwhen-.  It  is 
not  improbable  that  in  many  cases  the  course  of  the  disease  is  really  htnger  by 
several  days  than  would  appear,  both  by  the  existence  (.f  almost  la(«-nt  synip- 
toms  before  the  onset  and   by  llx-  persistence  for  some  days  of  the  infectiouH 


100  TYPHOID    FEVER. 

process  after  tlie  disappearance  of  the  fever.  Upon  the  whole,  I  incline  to 
think  that  abortive  typhoid  fever  is  more  common  in  America  than  is  gener- 
ally admitted.  A  more  critical  study  should  be  made  of  each  acute  febrile 
case,  and  a  lesson  of  greater  caution  in  treatment  be  learned.  The  peculiarities 
of  these  abortive  cases  may  depend  upon  a  modified  virulence  of  the  virus,  or 
more  probablv  upon  a  greater  resistance  on  the  part  of  the  tissues  and  system, 
with  comparatively  slight  intestinal  lesions  and  secondary  fever. 

The  mild  form  of  typhoid  is  of  more  importance  on  account  of  its  frequent 
occurrence.  As  a  rule,  the  course  and  duration  correspond  to  those  of  the  ordi- 
narv  tvpe,  save  that  all  the  symptoms  are  on  a  subdued  and  moderate  scale. 
Naturally,  a  considerable  proportion  of  the  short  abortive  cases  above  described 
are  also  included  under  this  heading.  The  onset  is  usually  gradual,  though 
sometimes  quite  severe  initial  symptoms  speedily  subside  and  give  place  to  a 
mild  type  of  the  fever.  The  temperature  shows  but  moderate  daily  variation, 
and  its  maximum  should  not  exceed  101°  or  102°  F.,  though  a  few  brief  rises 
to  103°  or  104°  F.  may  occur.  The  general  condition  of  the  patient  is  excel- 
lent, and  the  nervous,  pulmonary,  and  abdominal  symptoms  are  especially 
mild.  Epistaxis  often  occurs,  the  spleen  is  enlarged,  and  the  eruption  appears 
as  usual,  and  is  almost  as  likely  to  be  abundant  as  in  more  severe  cases.  Were 
it  not  for  these  cliaracteristic  symptoms,  the  case  might  be  regarded  as  one 
of  simple  continued  fever. 

It  must  never  be  forgotten  that  even  in  cases  of  such  mild  type  there 
is  danger  of  the  sudden  development  of  serious  complications.  Profuse  in- 
testinal haemorrhage,  or  even  perforation,  may  occur  when  all  the  previous 
symptoms  have  been  of  such  slight  grade  as  scarcely  to  warrant  the  least 
anxiety. 

Sporadic  cases  are  more  apt  to  be  mild  than  those  which  form  part  of  a 
decided  local  outbreak.  It  happens,  however,  that  in  some  seasons,  even 
when  the  disease  is  highly  prevalent,  a  large  proportion  of  all  the  cases 
assume  this  mild  and  favorable  type.  While,  therefore,  in  individual 
instances  the  type  may  depend  upon  want  of  susceptibility,  there  must  be 
at  times  associated  a  virus  of  less  than  usual  energy.  I  would  here  rej^eat 
the  caution  that  no  small  number  of  anomalous  febrile  disturbances  might 
be  found  on  careful  study  to  be,  in  fact,  typhoid  fever  of  very  mild  or 
abortive  form. 

Closely  associated  with  the  preceding  varieties  is  what  is  often  described  as 
the  afebrile  foria.  A  severe  epidemic  of  this  nature  occurred  in  the  German 
army  besieging  Paris  in  1870.  The  rose-colored  s})()ts  were  abundant,  there 
were  great  prostration,  slight  abdominal  symptoms,  and  violent  delirium  alter- 
nating with  stupor.  Though  in  some  instances  there  was  an  elevation  of  tem- 
perature lasting  not  more  than  two  weeks,  in  many  others  the  temperature  was 
normal,  or  even  subnormal.  All  the  cases  which  died  exhibited  the  charac- 
teristic lesions. 

Afebrile  typhoid  of  a  much  less  severe  form  is  reported  by  Liebermeister 
as  of  frequent   occurrence  in   Basle.     The  patients  suffered  from  lassitude, 


VARIETIES    (JF    TYPHOII)    FEVER.  101 

depression,  headache,  pains  througliont  the  body,  loss  of  appetite,  coated 
and  swollen  tongue,  slow  pulse,  constipation  or  diarrluva,  and,  in  many  cases, 
enlargement  of  the  spleen  and  rose-eolored  spots.  Tliey  were  often  confined 
to  bed  for  four  weeks  or  longer ;  yet  in  most  cases  no  elevation  of  tempera- 
ture whatever  was  detected  during  the  course  of  the  attack.  In  some  instances 
a  fever  of  100.5°  F.  was  occasionally  noted.  In  the  afebrile  cases  which  I 
have  seen  the  type  of  the  disease  lias  been  nn"ld,  and  there  has  been  a  subnor- 
mal temperature  at  some  period  of  each  twenty-four  hours,  so  that  tiie  diurnal 
variation  was  undulv  ffreat. 

The  latent  or  ambulatory  form  of  typhoid  fever,  or  "  walking  typhoid," 
is  only  a  variety  of  the  mild  form  of  the  disease.  It  is  marketl  by  an 
absence,  during  the  early  stages  at  least,  of  the  decided  sense  of  debility 
which  leads  the  patient  in  ordinary  cases  to  retire  to  bed  soon  after  the  inva- 
sion. In  this  form  it  is  not  unusual  to  find  the  ])atient  walking  about,  or 
even  attempting  to  pursue  his  occupation,  until  well  into  the  second  week. 
This  may  be  the  case  although  considerable  fever,  abundant  ernj)tion,  and 
some  diarrhoea  may  be  present.  Cases  of  this  type  are  met  with  most  com- 
monly among  the  working-classes,  and  especially  among  males  of  i>hlegmatic 
temperament.  I  have,  however,  seen  not  a  few  instances  among  women  en- 
gaged in  domestic  service.  There  is  an  almost  total  absence  of  nervous  symj)- 
toms,  and  this,  joined  with  the  fact  that  such  persons  are  rarely  accustomed  to 
note  carefully  or  to  attend  promptly  to  slight  distiu'banees  of  health,  may 
help  to  explain  the  marked  peculiarity  of  these^cascs.  They  are  more  gen- 
erally met  with  in  hospital  practice;  and  it  is  a  familiar  thing  in  every  large 
dispensary  service  to  find  ])atients  ap])]ying  with  complaints  of  diarrluea  or 
cramps  or  dyspepsia  who  on  examination  are  fi)und  to  have  a  temjieratiire 
of  102°  or  103°  F,,  with  characteristic  eruption,  enlarged  si)leen,  and  bronchial 
catarrh.  These  patients,  when  put  to  bed,  often  develop  symptoms  of  a  more 
severe  tyjie,  especially  if  they  have  travelled  far.  Sudden  delirium,  ])ro- 
*fuse  intestinal  haemorrhage,  or  even  perforation  of  the  intestine,  may  be  the 
first  indication  of  the  serious  nature  of  the  illness.  T  have  known  several 
cases  in  which  the  first  complaint  made  by  the  patient  was  only  after  intestinal 
perforation  had  occurred,  and  when,  after  death  in  the  course  of  twenty-four 
or  fi)rty-eight  hours,  examination  showed  advanced  lesions  corresponding  to  at 
least  the  condition  at  the  close  of  the  second  week.  The  evil  results  which 
follow  mental  or  bodily  effort  during  the  early  days  (.f  typhoid  fi-vi-r  are 
often  conspicuously  seen  in  these  cases.  It  is  probable  that  w(>re  rest  and 
suitable  care  secured  at  the  onset  they  wouM  habitually  nui  a  mild  cours(>. 

The  grave  forms  of  the  disease  may  ix-  eliaract(>rized  by  the  severity  of  (he 
symptoms  in  general,  dependent  upon  the  intensity  of  ihr  |)ni<on,  (.r  may  be 
marked  by  the  severity  of  certain  groups  of  symptom-^  whi.h  attain  an 
intensity  sufficient  to  warrant  (heir  elassifie!iti<.n  as  <-oinpli<-ations.  Where 
certain  symptoms  are  thus  especially  |)iuniin<nt  (inrini:-  tlie  :i(t:i<-k,  (he  disease 
may  be  again  divided  into  a  variety  of  ..(her  niin..r  luitns  .lepen.ling  U|)ou 
the    nature  of  the    prominently  dangerous   symptoms.      A   too    tuinnte  sub- 


102  TYPHOID    FEVER. 

division,    however,    only    complicates    the    subject,  and    but  a    few  varieties 
will  therefore  be  briefly  referred  to. 

The  disease  in  the  early  stages  of  the  grave  form  may  exhibit  no  specially 
alarming  features,  the  serious  aspect  of  the  case  developing  during  the  second 
week.  On  the  other  hand,  the  symptoms  may  from  the  beginning  be  espe- 
cially urgent  and  violent.  In  most  grave  cases  the  fever  runs  very  high 
and  is  attended  by  severe  nervous  symptoms.  Delirium  is  active  and  con- 
tinuous, and  sleep  is  secured  with  difficulty,  or  there  may  be  an  early  tend- 
ency to  deep  stupor.  When  delirium  is  marked,  and  Avith  great  muscular 
twitching  or  even  convulsions,  the  ataxic  or  cerebrospinal  form  is  i»poken  of. 
Where  prostration  begins  early  and  is  intense,  and  is  accompanied  by  great 
rapidity  of  the  pulse,  the  adynamic  form  is  present.  The  hcemorrhac/ic  form 
— a  very  grave  one — exhibits  a  special  tendency  to  the  occurrence  of  hoemor- 
rhaire  from  the  various  mucous  membranes  and  into  the  subcutaneous  cellular 
tissue,  and  indicates  serious  alteration  of  the  blood. 

In  some  grave  cases  the  nervous  system  may  be  comparatively  unaffected, 
while  alarming  abdominal  symptoms  appear,  such  as  extreme  distension  or 
profuse  and  uncontrollable  diarrhoea  [abdominal  form).  In  still  other  cases 
the  respiratory  symptoms  are  very  pronounced  from  the  start  (thoracic  form), 
and  the  intense  bronchial  congestion  and  catarrh  pass  into  pneumonia  with 
rapidly-failing  heart-power;  or  the  disease  may  begin  with  pneumonia,  as 
already  stated. 

A  variety  of  grave  typli^id  fever  has  been  described  as  the  renal  form. 
In  this,  already  referred  to  in  discussing  the  variations  in  onset,  the  urine  early 
exhibits  albumin,  blood,  and  casts.  Cases  have  been  observed  which  simulate 
acute  nephritis,  and  in  one  instance  reported  by  Thue  even  the  autopsy  did  not 
render  the  diagnosis  certain  until  a  bacteriological  examination  had  been  made. 

Other  forms  of  typhoid  fever,  described  by  some  writers,  are  the  gastric  or 
bilious  ;  the  mucous,  some  cases  of  which  are  probably  identical  with  the  last, 
while  others  are  to  be  classed  under  abortive  typhoid  ;  spleno-typhoid,  in  which*^ 
the  spleen  is  greatly  enlarged  and  the  symptoms  closely  resemble  those  of 
relapsing  fever;  and  the  sudoral  form,  characterized  by  profuse  sweating, 
particularly  at  such  periods  in  the  day  that  the  probability  of  the  disease 
being  malarial   is  suggested. 

Finally,  there  is  what  may  be  called  the  malignant  form  of  tyjihoid  fever, 
called  also  the  septicemic  form.  The  quality  of  malignancy  does  not  exhibit 
itself  in  this  disease  nearly  so  often  as  in  some  other  infectious  diseases,  such 
as  typhus,  scarlet,  and  cerebro-spinal  fevers.  In  severe  local  outbreaks  of  the 
disease,  however,  there  may  be  a  small  proportion  of  cases  which,  from  the 
very  outset,  are  of  a  malignant  character.  The  onset  is  violent,  the  fever 
rapidly  rising  to  a  high  point  and  differing  widely  in  this  respect  from  the 
ordinary  mode  of  development;  symptoms  of  profound  nervous  disturbance, 
such  as  stupor,  active  delirium,  or  even  convulsions,  make  their  ap])earance 
early;  the  mouth  and  tongue  quickly  become  coated  with  copious  dark  sordes; 
there  is  deep  discoloration  of  the  skin,  forming  at  dependent  parts,  especially 


RELAPSE  AND    liECUHREXCE.  1(»;^ 

where  pres.surc  is  exerted,  aiul  marked  hypostatie  conjrestion  of  the  hinjrs 
occurs.  If  life  be  prolonged  until  the  appearance  of  tlic  eruption,  the  sp.^ts 
may  be  unusually  dark  and  petechiiij  may  devcK)p.  Siu-h  cases  arc  generally 
fatal,  and  it  is  not  uncommon  for  death  to  occur  by  tlio  soventh  or  tenth 
day  or  even  earlier. 

It  is  important  to  observe,  before  leaving  tiie  sid)ject,  \W  iuHuoncc  of  the 
pei'iod  of  life  in  determining  the  wliolc  course  of  tlic  disease. 

Ti/phoid  fever  in  i)if(i)tts  and  children  formerly  passed  under  the  name  of 
infantile  remittent  fever,  on  account  of  the  erroneous  belief  that  tvphoid  fever 
did  not  occur  at  so  early  an  age.  So  far  from  tliis  being  the  tiutli,  the  disease 
is  very  common  in  early  life,  though  it  is  usually  less  severe  and  often  of 
shorter  duration.  The  temperature  generally  rises  more  ra|)i(llv  and  is  nu.re 
apt  to  assume  a  remittent  type,  and  to  fall  by  crisis.  The  eru])ti<.n  is  often 
absent  or  slight,  and  epistaxis  is  rare.  The  pidse  is  more  ra|)id,  but  not  so 
dicrotic.  Intestinal  symptoms  are  wanting  or  slight,  but  vomiting  iseonnnon, 
at  least  at  the  outset  of  the  disease.  Bronchitis  is  frecpient,  though  catarrhal 
pneumonia  is  not  a  common  complication.  Nervous  symptoms  are  variable: 
in  some  cases  convulsions  occur  at  the  onset  or  mav  be  devcloned  bv  an  indis- 
cretion  in  diet  or  treatment,  and  delirium  and  stupor  are  marked.  In  other 
instances  there  is  even  but  little  hebetude  throughout.  Intestinal  lucmorrhaire 
or  perforation  is  rare.  I  have,  however,  met  with  fatal  general  peritonitis 
without  perforation  in  a  child  of  five  years.  The  mortality  is,  upon  the  whole, 
very  small. 

Typhoid  fever  in  advanced  life  or  after  the  age  of  Jiff  j/  years  becomes  nmch 
more  serious  than  at  earlier  periods.  The  onset  is  often  insidious.  The 
fever  does  not  run  high  as  a  rule,  but  is  prolonged,  and  during  convalescenee 
the  temperature  is  liable  to  fall  below  normal,  with  a  tendency  to  collapse. 
The  eruption  is  less  constant,  as  are  also  epistaxis  and  severe  diarrhoea.  The 
nervous  symptoms  assume  the  adynamic  and  ataxic  tyjies.  A^iolent  delirium 
is  uncommon,  but  great  prostration,  tremor  and  subsidtus,  increasing  <lulness 
and  stupor,  retention  of  urine  or  involutary  evacuations,  are  frequent.  The 
tongue  grows  dry,  hard,  and  brown,  an<l  it  often  becomes  very  dinieult  to 
nourish  the  patient.  Hypostatic  pneumonia  and  nephi-itis  are  fre(|ii(iit  com- 
plications. It  is  often  difficult  to  decide  whether  the  case  be  actually  one  of 
tyi)hoid  fever  or  of  pneumonia  of  a  low  grade  with  typhoid  symj)toms  ;  of 
cerei)ral  thrombosis  or  meningitis  with  development  of  similar  sympt(»ms;  (»r 
of  uncmia. 

Relapse  and  Recurrence. — The  term  ■'  relapse  "  is  employed  to  desigu.ite 
a  renewal  and  rei)etition  of  a  mori)rd  process  occurring  before  heallli  is  re-es(ab- 
lished  after  the  primary  attack.  It  is  to  be  clearly  distinguished,  therefore, 
on  the  one  hand,  from  any  mere  sef|uc]  or  accidental  airccti(»n  arising  during 
convalescence,  and,  on  the  other,  from  a  recurrence,  which  is  a  trn<'  sci-ond 
attack  of  the  disease,  separated  fr('»m  the  (.rigitial  attack  by  a  more  or  lc<s  eon- 
siderable  period  of  health. 

One  of  the  most  remarkable  features  of  typhoid  fever  is  the  frequency  with 


104  TYPHOID    FEVER. 

wliicli  a  relapse  of  the  disease  occurs.  It  is  difficult  to  determiue  in  what  pro- 
portion of  cases  this  takes  place.  Murchison  estimated  it  at  as  low  as  3  per 
cent. ;  Gerhardt  noted  relapse  in  6.3  per  cent,  of  4000  cases  ;  Jaccoud  and 
Sciimidt  found  it  in  about  9  per  cent,  of  their  cases.  It  is  evident  that  the 
tendency  to  relapse  varies  in  different  seasons  and  localities,  so  that  the  pro- 
portion may  be  as  low  as  1  per  cent,  or  as  high  as  10  per  cent,  or  15  per  cent., 
or  even  more. 

It  has  already  been  seen  that  during  the  convalescence  of  typhoid  fever 
sudden  and  brief  elevations  of  temperature  are  likely  to  follow  fatigue,  excite- 
ment, or  errors  in  diet.  These  are  styled  recrudescences.  Anxiety  is  always 
felt  when  this  takes  place,  lest  it  may  be  the  beginning  of  a  relapse,  but  the 
subsidence  of  the  fever  in  a  day  or  two  allays  alarm.  So  also  fever  attends 
some  of  the  sequels  which  appear  during  convalescence,  such  as  phlebitis  or 
periostitis.  A  good  example  of  this  is  seen  in  Fig.  6,  where  the  second 
febrile  period  was  connected  \vith  phlebitis.  It  would  have  been  easy  to 
overlook  its  true  nature,  and  it  is  not  improbable  that  many  so-called 
relapses  are  really  due  to  undiscovered  sequelae. 

Relapses  occur  most  frequently  in  the  second  or  third  week  of  convales- 
cence, after  an  absence  of  fever  for  several  days  (one  to  twenty) ;  but  they  may 
develop  before  the  patient  has  become  entirely  apyretic,  thus  explaining  some 
of  the  long-continued  cases  of  typhoid  fever. 

To  constitute  a  true  relapse  there  should  be  an  absence  of  all  irritative  se- 
quela? adequate  to  explain  the  fever;  the  elevation  of  temperature  should  pre- 
sent more  or  less  clearly  the  step-like  mode  of  ascent  which  marks  the  original 
onset;  enlargement  of  the  spleen  should  recur,  and  eruption  may  reappear. 
It  is,  indeed,  true  that  the  prodromal  stage  is  usually  wanting  in  relapses,  and 
the  temperature  is  apt  to  mount  more  rapidly  and  by  longer  steps  than  in 
primary  attacks.  So  also  the  eruption  appears  at  an  earlier  date,  often  being 
visible  on  the  third  or  fourth  day  of  the  fever.  I  am  inclined  to  think  that 
the  eruption  is  about  as  frequent,  but  apt  to  be  less  abundant,  in  relapses  as 
in  ])rimary  attacks.     I  have,  however,  seen  it  much  more  copious. 

TIk!  fever  curve  in  relapses  is  even  more  variable  as  to  range  and  duration 
than  in  primary  attacks.  In  general,  there  may  be  some  correspondence 
between  them  in  individual  cases,  but  more  commonly  the  fever  neither  runs 
so  high  nor  so  long  as  at  first.  It  is  not  unusual  for  it  to  terminate  by  lysis 
at  the  end  of  from  ten  to  fourteen  days,  though  it  may  be  even  shorter,  or  in 
some  cases  may  persist  three  full  weeks.  Nervous  symptoms,  especially  head- 
ache, delirium,  and  tremor,  often  recur,  and  may  appear  early.  Abdominal 
symptoms  are  usually  less  marked. 

Upon  the  whole,  relapses  are  less  severe  than  the  primary  attacks.  There 
is,  however,  no  reliable  rule  in  regard  to  this  point,  and  I  have  seen  cases 
in  which  the  original  attack  Avas  mild,  but  the  relapse  violent  and  fatal. 
Murchison  states  that  of  the  53  instances  of  relapse  observed  by  him,  one-third 
were  more  severe  than  the  primary  attack.  The  dangers  of  the  relapse  are 
the  same  as  those  of  original  attack,  but  less  in  degree  as  regards  diarrhoea, 


DIAGXOSIS.  105 

haemorrhage,  and  perforation,  while  there  is  added  risk  of  exhaustion,  due  to 
the  ah-eady  weakened  state  of  the  patient. 

In  rare  instances  a  second  or  even  a  third  reiai)se  may  occur  after  successive 
periods  of  apparent  convalescence,  so  that  the  entire  process  may  o<'cupy  months. 
These  later  relapses  are,  as  a  rule,  but  not  invariably,  milder  and  shorter  in 
their  turn  than  either  the  primary  attack  or  the  first  relapse. 

Hutchinson  reports  a  case  in  which  the  third  relapse  occurretl  nearly  four 
months  after  the  patient  was  first  taken  ill  ;  Chantemesse,  one  in  which  the 
whole  course  of  the  disease  thus  extended  throu<rh  five  months  ;  and  I  have 
attended  a  patient  for  one  hundred  and  twenty  days  through  a  severe  primary 
attack  and  three  equally  severe  relapses  to  full  recovery.  In  the  bodies  of 
those  who  have  died  in  a  relapse  the  intestine  exhibits  two  sets  of  lesions — 
those  of  the  first  attack  in  process  of  cicatrization,  together  with  fresh  ulcers 
of  the  second  attack,  although^  these  latter  are  less  numerous  and  are  situated 
higher  in  the  ileum. 

The  cause  of  relapse  is  clearly  a  reinvasion  of  the  blood  by  the  bacilli. 
What,  however,  occasions  the  reinvasion  is  not  understood.  It  has  been  sup- 
posed that  a  reinfection  from  without  the  body  may  be  at  fault,  but  this  theory 
is  certainly  not  tenable  in  more  than  a  small  proportion  of  cases.  Doubtless  the 
reinfection  is  more  commonly  from  within  by  bacilli  which  have  been  thrown 
oif  in  the  sloughs  from  the  ulcers,  or,  more  probably,  by  those  which  have 
been  deposited  in  foci  somewhere  in  the  internal  organs.  It  is  important  to 
emphasize  the  fact  that  statistics  have  shown  conclusively  that  relapses  are  no 
more  frequent  in  cases  which  have  been  treated  by  cold  baths  after  the  methotl 
of  Brand. 

Recurrences  or  Subsequent  Attacks. — The  immunity  afionlcd  to  the  sys- 
tem by  passing  through  an  attack  of  typhoid  fcv(M-  is  usually  complete  and 
lasting.  Subsequent  attacks  do,  however,  occur,  although  rarely.  A  study 
of  (300  cases  made  by  Eichhorst  showed  the  occurrence  of  a  second  attack  28 
times,  or  in  4.7  per  cent.  A  few  instances  of  even  three  or  four  attacks  in  one 
person  were  included  in  the  series  of  cases.  I  have  attended  several  patients 
through  two  characteristic  attacks  of  typhoid  fever,  and  have  had  more  than 
one  apparentlv  reliable  account  given  mc  of  three  distinct  attacks  at  inter- 
vals of  several  years.  According  to  general  observation,  second  attacks  of 
tvphoid  are  more  common  in  men  than  in  women,  and  arc  milder  in  type 
than  the  original  one. 

Diag-nosis. — The  whole  question  of  the  diagnosis  of  typlioid  lever  should 
be  dominated  by  the  view  that  this  disease  is  much  more  likely  to  exist  and 
to  be  overlooked  than  that  other  alleetions  should  be  mistakrn  for  it  ;  and 
further,  that  in  doubtful  cases,  whatever  may  i)e  their  natinv,  lh<-  |Kiti.ii(  will 
usually  bonelit  by  receiving  fr(»m  the  beginning  of  his  sickness  the  rigid  care 
and  treatment  appropriate  if  it  should  i)rove  to  be  typhoid. 

After  the  first  week  of  the  disease  the  diagn«.sis  l)(v..iiics  cjtsy  in  typical 
cases.  In  this  first  week,  however,  aii<l  even  alter  il  in  atypical  cases,  it  may 
be  very  difficult.     Still,  a  diagnosis  possessing  a  high  dej^'rec  of  pn.bability 


106  TYPHOID    FEVER. 

can  usuallv  be  made  early  in  the  affection.  The  progressive  lassitude,  dulness, 
headache,  anorexia,  and  gradually  increasing  fever  with  marked  morning 
remissions,  render  the  case  very  suspicious,  especially  if  these  symptoms  are 
combined  with  epistaxis,  diarrhoea,  and  enlargement  of  the  spleen.  If  after 
the  fever  has  lasted  a  week  lenticular  spots  develop,  the  diagnosis  becomes  cer- 
tain. Even  without  their  presence,  however,  the  continuance  of  fever  of  more 
or  less  characteristic  type,  the  hebetude  and  developing  nervous  symptoms, 
the  diarrhoea  and  abdominal  distension,  the  epistaxis  and  bronchial  catarrh, 
strongly  confirm  our  suspicions,  and,  in  the  absence  of  any  other  demonstrable 
infection  or  local  lesion  to  explain  the  symptoms,  justify  a  working  diagnosis 
of  typhoid  fever. 

More  difficult  to  recognize  are  the  atypical  cases  which  begin  with  or 
early  develop  an  intense  localization  of  the  disease  in  certain  organs.  It  has 
already  been  shown  that  typhoid  fever  in  which  the  initial  localization  is  in 
the  lungs  may  closely  simulate  a  primary  pneumonia.  In  both  conditions 
the  cerebral  symptoms  may  be  marked,  the  fever  may  rise  rapidly,  and  albu- 
minuria may  be  present.  In  typhoid,  however,  the  gravity  of  the  general 
symptoms  soon  seems  out  of  proportion  to  the  extent  of  the  local  lesion  ;  the 
spleen  is  more  decidedly  enlarged  ;  epistaxis  is  more  common,  as  is  also  bron- 
chial catarrh  on  the  side  unaffected  with  pneumonia;  abdominal  distension  and 
diarrhoea  are  more  pronounced,  and  later  the  appearance  of  rose  spots  and  the 
absence  of  herpes,  and  the  failure  of  crisis  to  occur  on  the  twelfth  or  fourteenth 
day,  serve  to  establish  the  diagnosis. 

The  insidious  development  of  pneumonia  during  the  course  of  typhoid 
fever  will  often  be  overlooked  unless  daily  examination  of  the  chest  be  made 
systematically.  It  must  be  borne  in  mind,  also,  that  when  in  the  course  of 
pneumonia,  and  especially  in  elderly  people,  the  typhoid  state  ensues,  there 
may  be  developed  a  group  of  symptoms  indistinguishable  from  those  of 
typhoid  fever  save  by  the  absence  of  eruption  and  by  the  history  of  the 
case. 

Typhoid  fever  beginning  with  marked  nervous  symptoms  may  readily  be 
mistaken  for  cerebrospinal  fever.  Such  cases  present  rapid  rise  of  tempera- 
ture to  a  high  point,  severe  headache  and  delirium,  stiffness  of  the  muscles  of 
the  neck  and  retraction  of  the  head,  muscular  twitching,  and  even  some  degree 
of  general  muscular  rigidity  and  soreness.  The  suggestion  of  meningitis 
may  indeed  be  so  forcible  that  a  differential  diagnosis  is  impossible  for 
several  days.  Attention  may  be  drawn  to  the  following  points :  that  in 
cerebro-spinal  fever  the  onset  is  usually  even  more  abrupt,  the  pain  in  the 
head  more  intense,  and  the  stiffness  of  the  neck  and  retraction  of  the  head 
earlier  and  more  marked  ;  that  vomiting  is  more  common,  while  the  abdomen 
is  apt  to  be  retracted  and  the  bowels  constipated  ;  that  the  nervous  symptoms 
persist  and  progress,  instead  of  yielding,  as  those  in  typhoid  may  in  some 
degree,  to  suitable  treatment ;  that  epistaxis  is  wanting  and  enlargement  of 
the  spleen  less  constant  and  marked,  while  herpes  is  very  common.  Of  course 
the  diagnosis  between  ordinary  cases  of  these  two  diseases  gives  no  difficulty. 


I 


DIAdXOSIS.  1(»7 

and  the  above  remarks  apply  only  to  the  cerebro-spinal  type  of  tvphoitl 
fever. 

Simple  continued  fever  may  greatly  resemble  mild  oases  of  tvphoid  fever. 
It  is  common  to  meet  with  patients  who  exhibit  for  a  wei-U  or  more  a  fever 
of  continned  type  for  which  no  satisfactory  cause  can  be  discovered,  and  the 
exact  nature  of  which  must  often  remain  in  doidjt,  even  alter  convalescence. 
The  more  abrupt  onset,  the  absence  of  characteristic  temperature  curve  or 
eruption,  the  comparative  infrequency  of  marktHl  nervous  or  abdominal  svmp- 
toms,  of  epistaxis,  or  of  splenic  enlargement,  tend  to  exclude  tvphoitl  fever 
in  the  diagnosis. 

Typhus  fever  is  usually  distinguished  with  ease  from  typhoid,  ("oufusion 
may  arise  in  rare  instances,  either  from  the  presence  of  a  j)rofuse,  dark-<-olorcd 
eruption  in  the  latter  disease,  or  the  occurrence  of  diarrhoea  in  the  former.  As 
a  rule,  the  character  of  the  eruption  will  satisfactorily  distinguish  the  two  atfW'- 
tions.  That  of  typhus  often  appears  as  early  as  the  fourth  day,  is  copi(»ns,  and 
consists  of  dusky-red,  irregular  spots  which  do  not  entirely  disappear  on  pres- 
sure. In  addition  to  this,  the  onset  of  typhus  fever  is  sudden,  the  fever  is 
more  continuous  in  type,  the  pupils  are  contracted,  petechiie  are  common, 
abdominal  symptoms  of  any  sort  are  infrequent,  and  the  disease  is  of  shorter 
duration  and  more  apt  to  terminate  abruptly.  A  more  full  statement  of  the 
points  of  differential  diagnosis  will  be  foinid  under  the  head  of  Typhi's 
Fp:ver. 

Relapsing  fever  can  scarcely  be  mistaken  for  tyj)hoid  fever,  since  the  wiidle 
history  of  the  two  diseases  is  so  entirely  different.  Relapsing  fever  has  a  sud- 
den onset,  with  continued  high  fever,  which  lasts  a  definite  time  and  terminates 
by  crisis ;  and  this  process  repeats  itself  after  an  interval  of  a  week.  There 
are  none  of  the  symptoms  of  tyjihoid  fever  attendant  uj>on  the  disease,  while 
jaundice  is  more  liable  to  occur,  with  i)ain  in  the  upper  portion  of  the  abdomen. 

Bemittent  malarial  fever  may  simulate  tyjihoid  fever  very  closely.  Diar- 
rhoea, vomiting,  epistaxis,  splenic  enlargement,  and  cerebral  symptom-^  may 
exist  alike  in  botii.  The  locality  and  the  history  of  the  case  should  b(>  con- 
sidered. An  absence  of  i)rodromes  ;  a  sudden  onset ;  marked  gastro-hcpati(r 
disturbance  with  bilious  symptoms  and  even  jaundice;  the  occurrence  of  hei-pcs, 
but  no  rose-colored  spots;  and  fever  of  markedly  and  regularly  remittent  type, 
attended  with  ])rofuse  sweating, — point  to  the  malarial  nature  of  the  iliseasc 
The  decided  effect  of  a  full  dose  of  a.  cinchona  salt,  given  as  a  therapeutic 
test,  is  an  important  help  in  diagnosis ;  and  linally  an  examination  may  be 
made  for  malarial  organisms  in  the  blood. 

It  is  necessary  to  bear  in  mind  that  arKfc  miU'irii  fiihrrciiloxitt,  which  is 
happily  of  rare  occurrence,  may  readily  be  mistaken  lor  typhoid  fever.  In 
both  affections  there  is  a  prodromal  stage,  with  anniv\i:i,  progress!  vly  in.ivas- 
ing  fever,  cough  and  bronchitis,  headache,  and  <leliiinni  passing  int.)  stnpur. 
But  unless  there  is  abdominal  as  well  as  meningeal  tubcrcidosis  ih.-rc  will  be 
neither  tympanites  nor  diarrhfea,  as  in  typhoid  fever,  but  rather  con>.tipMli.wj 
with  retracted  belly  and  cerebral  vomiting.     The  temperature  curve  in  tnb.T- 


108  TYPHOID    FEVER. 

culosis  is  hio-hlv  irregular ;  the  pulse  presents  important  variations  at  successive 
stao-es ;  respirations  are  hurried  out  of  "proportion  to  any  demonstrable  pulnio- 
narv  lesion  ;  strabismus,  double  vision,  and  local  palsies  may  appear;  eruption 
is  wanting ;  epistaxis  is  rare  ;  ^nd  splenic  enlargement  is  less  constant  and 
marked  than  in  typhoid. 

Hughlings-Jackson  states  that  an  important  diagnostic  sign  between  typhoid 
fever  and  tubercular  meningitis  consists  in  the  fact  that  the  knee-jerk  is  never 
absent  in  the  former,  while  in  the  latter  it  is  variable — present  one  day,  absent 
another,  increased  another.  In  this  view  he  is  sustained  by  Money.  The  diazo- 
reaction  (jf  the  urine,  once  supposed  to  be  characteristic  of  typhoid  fever,  occurs 
in  tuberculosis  as  well.  Leucocytosis  is  present  in  acute  miliary  tuberculosis, 
whereas  in  typhoid  fever  the  number  of  leucocytes  is  often  diminished.  In  all 
doubtful  cases  an  ophthalmoscopic  examination  should  be  made.  Although  the 
failure  to  discover  choroidal  tubercles  affords  only  negative  evidence  in  favor  of 
typhoid,  their  detection  is  of  course  proof  positive  of  the  tuberculous  nature  of 
the  case. 

Primary  peritoneal  tuberculosis,  especially  in  children  without  j)recedent 
pulmonary  lesion,  may  occasionally  cause  temporary  hesitation  in  diagnosis, 
but  the  irregular  fever,  the  absence  of  cerebral  and  bronchial  symptoms,  as 
well  as  of  eruption,  and  the  widely  diiferent  course  of  the  case  will  soon 
clear  up  the  doubt. 

Influenza  may  resemble  typhoid  fever  in  exhibiting  great  prostration  with 
early  bronchitis,  and  sometimes  epistaxis,  combined  with  sleeplessness,  fever, 
and  perhaps  delirium.  Diarrhoea  also  often  occurs  in  it,  and  the  typhoid  state 
may  develop.  The  disease  is  distinguished,  however,  by  the  shorter  duration, 
absence  of  rose-colored  spots,  of  abdominal  symptoms  other  than  diarrhoea, 
and  of  the  characteristic  temperature  curve. 

Scarlatina  could  only  be  confounded  with  typhoid  fever  in  those  cases  of 
the  latter  disease  in  which  the  development  of  the  characteristic  eruption  is 
preceded  for  several  days  by  a  scarlatinal  efflorescence.  Even  in  such  there  is 
little  chance  for  error  if  the  mode  of  onset  and  the  symptoms  in  general  be 
carefully  studied. 

Trichiniasis  resembles  typhoid  fever  in  exhibiting  vomiting,  diarrhoea, 
fever,  and,  later,  symptoms  of  the  typhoid  state.  In  no  other  respect  are  the 
two  diseases  alike.  The  muscular  pain  and  oedema  of  trichiniasis  are  not  seen 
in  typhoid  fever. 

Those  cases  of  typhoid  fever  which  begin  with  marked  mental  symptoms 
may  sometimes  be  mistaken  for  insanity.  The  same  is  true  of  cases  first  seen 
at  the  height  of  the  disease,  and  of  which  no  previous  clinical  history  can  be 
obtained.  A  systematic  employment  of  the  clinical  thermometer  and  a  care- 
ful observation  of  the  symptoms  will  ensure  the  avoidance  of  any  such  error 
in  diagnosis. 

G astro-intestinal  catarrh  at  times  produces  a  group  of  symptoms  highly 
suggestive  of  ty])hoid  fever.  Either  as  the  result  of  a  profound  im})ression 
made  by  unfavorable  atmospheric  influences  upon  a  morbidly  sensitive  ali- 


DUBATiox,  pno(rX()s/\\  MoirrMJTV.  i(n» 

mentary  tract,  or  ot'tlie  ingestion  of^onie  non-spoc-itio  toxic  agent,  an  obstinate 
subacute  catarrhal  i)rocess  is  started  which  may  for  several  weeks  keep  up 
irregular  fever  of  moderate  degree,  coated  tongue,  anorexia,  inital)iiity  of 
stomach  and  bowels,  abdominal  distress,  marked  debility,  and  mild  lu'rvous 
symptoms,  such  as  headache  and  restlessness.  In  children  the  nervous  symp- 
toms may  be  more  marked.  Epistaxis  is,  however,  uncommon  ;  the  sj)leen  is 
not  enlarged ;  bronchial  symptoms  are  wanting  ;  there  is  no  characteristic 
eruption;  and  the  course  of  the  disease  is  wholly  irregular.  \\'hen  the  wide 
irregularities  of  a  tyjiical  typhoid  are  recalled,  it  must  be  admitted  that  it  mav 
occasionally  be  impossible  to  arrive  at  a  positive  diagnosis  ;  under  which  cir- 
cumstances the  patient  should  have  the  bencht  of  the  doubt,  and  be  treated 
as  though  in  a  mild  typhoid  fever. 

Uvoemia  may  develop  gradually  and  pass  into  a  typical  typhoid  state.  I 
have  met  with  this  condition  most  frequently  at  or  after  middle  life  and  in 
connection  with  chronic  interstitial  nephritis.  The  facial  expression  and  men- 
tal state  are  curiously  like  those  of  typhoid  fever;  a  low  grade  of  fever  with 
bronchial  and  gastro-intestinal  catarrh  is  not  unusual,  so  that  I  have  repeat- 
edly been  asked  to  see  such  cases  as  instances  of  anomalous  and  j)rotract(Hl 
typhoid.  The  detection  of  arterio-sclerosis  and  cardiac  hypertrophy  and  albu- 
minuria with  casts,  the  odor  of  the  breath,  the  absence  of  eruptit)n,  epis- 
taxis, and  splenic  enlargement,  and  the  history  and  course  of  the  case,  will 
serve  to  establish  a  diagnosis. 

Duration,  Prognosis,  Mortality. — The  onset  of  typhoid  lever  is  usually 
slow  and  insidious,  so  that  it  is  diiiicult  to  determine  the  exact  date  of  com- 
mencement or  the  total  length  of  the  attack.  In  many  instances  the  duration 
can  be  only  approximately  estimated.  More  rarely  the  suddenness  or  severity 
of  the  early  symptoms  permits  of  a  positive  decision.  The  average  duration 
of  the  attack  is  three  to  four  weeks.  IJartlett  estimated  it  at  22  days  in 
255  cases,  and  Murchison  at  24.3  days  in  200  cases  which  reec.vered,  and 
at  27.67  days  in  112  cases  which  did  not.  Wh(>n  fever  continues  alter  the 
twenty-eighth  day  some  complication  may  be  susi)ected,  yet  the  last  stage  of 
the  di.sease  is  occasionally  prolonged  for  several  days  bey(»nd  this  date  without 
discoverable  cause.  So  slight  a  local  irritation  will  th(Mi  suirice,  however,  to 
maintain  or  to  revive  fever  that  such  a  cause  may  be  strongly  suspected.  The 
extremelv  prolonged  course  pursued  by  cases  where  one  or  more  relai)s(>s  oe(  ur 
has  already  been  fully  alluded  to. 

Typhoid  fever  may,  on  the  other  hand,  end  considerably  within  the  average 
period.  In  abortive  cases  it  lasts  no  more  than  fioiu  ten  d:iys  t<.  two  weeks. 
Indeed,  some  of  the  abortive  mild  cases  run  so  >liort  a  e.Muve  that  the  alVee- 
tion  is  recognized  with  difficidty. 

The  date  of  death  in  fatal  cases  is  no  less  variable.  In  very  grave  cases 
the  disease  mav  i)rove  fotal  as  early  as  the  fifth  ..r  sixth  day.  an-i  in  the  malig- 
nant form  .leaili  mav  occur  ..n  the  third,  seeond.  or  even  on  the  very  fn-st  day. 
On  tl,.'  other  hand,  "it  may  result  from  exhaustion  or  from  some  sequel  or  pro- 
tracted complication  long  after  the  specific  disease  has  itsell"  en.led.     'i'h.'  (ever 


110  TYPHOID   FEVER. 

which  may  attend  such  cases  is  manifestly  irritative  or  septic,  and  not  due  to 
specific  typhoid  infection.  It  has  already  been  stated  that  death  may  occur 
in  a  relaj)se  although  the  original  attack  has  been  a  mild  one. 

In  o-eneral  it  may  be  stated  that  the  third  week  is  the  period  of  greatest 
mortality  in  tvphoid  fever.  Death  is  comparatively  rare  before  the  fourteenth 
day,  and,  although  less  rare  after  the  twenty- first  day,  is  still  not  so  frequent 
then  as  in  the  third  week. 

The  immediate  causes  of  death  are  numerous  and  varied.  Toxsemia  and 
cerebral  exhaustion,  associated  with  coma,  with  or  without  hyperpyrexia,  cause 
death  in  many  cases,  especially  from  the  beginning  of  the  third  week  onward. 
In  some  instances  ura?mia,  owing  to  a  high  grade  of  nephritis,  plays  a  part  in 
causing  this  condition.  Hyperpyrexia,  at  whatever  date  it  may  develop,  is 
often  fatal  unless  promptly  subdued.  It  speedily  induces  nervous  exhaustion 
and  cardiac  failure,  partly  of  nervous  and  partly  of  muscular  origin.  Intense 
asthenia  is,  as  woidd  be  expected,  a  fruitful  source  of  death  in  this  disease. 
It  may  come  on  rather  gradually  and  late  in  the  disease  as  the  result  of 
continued  high  fever,  of  sleeplessness,  of  vomiting,  of  diarrhoea,  or  of  re- 
peated nasal  or  intestinal  haemorrhages.  Or  sudden  collapse  may  occur  from 
a  single  large  haemorrhage,  from  profuse  diarrhcea,  from  the  shock  of  perfora- 
tion, or  from  direct  cardiac  failure.  There  are  various  ways  in  which  cardiac 
failure  may  be  induced.  The  mechanical  effect  of  extreme  tympanites,  causing 
great  upward  displacement  of  the  diaphragm,  may  co-operate.  Advanced  de- 
generation of  the  cardiac  fibre,  due  to  intense  toxsemia  and  high  fever,  and 
possibly  also  acute  changes  in  the  cardiac  or  pneumogastric  ganglia,  serve  to 
explain  the  extreme  loss  of  contractile  power  or  the  violent  disturbance  of 
innervation  (delirium  cordis)  which  often  precedes  and  hastens  death.  Sud- 
den death  may  occur  from  cardiac  or  pulmonary  embolism  ;  from  the  entrance 
of  gas  into  an  intestinal  vein  ;  from  convulsion,  whether  ursemic  or  not ;  from 
cardiac  paresis,  due  to  imprudent  effort;  from  enormous  haemorrhage. 

Severe  bronchitis,  pneumonia,  pleurisy,  or  other  complication  may  turn  the 
scale  against  the  patient.  It  is  evident,  therefore,  that  from  the  earliest  day 
to  the  completion  of  convalescence  there  is  ground  for  constant  uncertainty  and 
anxiety. 

The  exhausting  effects  of  bed-sores,  or  of  large  centres  of  sup])uration,  as 
in  the  parotids,  may  prove  fatal  even  after  all  the  ordinary  dangers  of  the  dis- 
ease have  apparently  been  esca])ed. 

The  mortality  of  tyj^hoid  fever  has  been  calculated  almost  exclusively  from 
hospital  statistics.  It  is  evident  that  these  are  to  some  extent  misleading, 
since  many  cases  are  admitted  too  late  to  be  amenable  to  any  treatment  what- 
ever, and  the  rest  are  only  too  apt  to  have  undergone  such  exertion  or  expo- 
sure in  the  early  days  of  the  disease  as  to  materially  increase  its  dangers.  It 
must  be  remembered  also  that  the  mortality  of  typhoid  fever  varies  much  in 
different  epidemics  and  apparently  in  different  localities.  Study  of  the  most 
extensive  statistics  available  indicates  that  before  the  introduction  of  the  Brand 
method  of  treatment  by  systematic  cool  baths  the  mortality  of  typhoid  fever  in 


DUBATIOX,    PROaXOSIS,    MO  Ji  TALI  TV.  Ill 

liospitals  varied  from  10  to  30  per  cent.,  but  most  commonly  rangetl  between 
15  and  25  per  cent.  It  i.s  impossible  to  avoid  drawini;  the  conclusion,  from 
recent  statistics,  that  in  those  institutions  where  the  Brand  method  has  been 
used  the  mortality  has  been  reduced  abruptly,  and  without  other  ascertainable 
cause,  to  from  5  to  8  per  cent.  Undoubtedly,  the  modern  antipyretic  methods, 
even  without  the  use  of  full  baths,  have  been  of  vast  service  in  the  treatment 
of  ty})hoid,  especially  in  private  practice,  where  as  yet  the  Brand  system  has 
been  used  but  rarely.  Xo  accurate  figures  are  available  on  any  large  scale, 
but  from  numerous  inquiries  I  incline  to  believe  that  the  mortality  of  typhoid 
fever  in  private  practice  is  not  less  than  10  per  cent.  It  happens  occasionally 
that  a  large  series  of  cases  will  occur  without  a  single  death.  I  have  myself 
treated  100  consecutive  cases  in  private  practice  without  a  fatality,  and  I  know 
of  several  series  of  100  cases  with  a  mortality  of  only  1  to  2  i)er  cent. 

The  prognosis  of  typhoid  fever  is  very  difficult  to  estimate,  and  is  iullii- 
enced  bv  general  considerations  and  by  special  symptoms. 

The  disease  is  decidedly  less  fatal  in  children  from  infancy  u{>  to  puberty. 
I  have  observed  that  in  young  persons  who  have  been  growing  very  rapidly 
the  nervous  svmptoms  and  the  asthenia  are  apt  to  be  marked  and  the  disease 
dangerous.  The  mortality  increases  rapidly  after  forty-five  years  of  age.  Sex 
exerts  no  definite  influence.  Most  of  the  statistics  show  an  excess  of  deaths 
among  females  of  about  1   per  cent. 

Season  does  not  appear  to  liave  any  effect  on  the  mortality.  The  varying 
reports  are  probably  due  to  the  different  gravity  of  the  outbreaks.  Cases 
occurring  during  protracted  spells  of  intense  heat  are  undoubtedly  more  apt 
tt)  be  fatal. 

The  station  in  life  is  without  influence  on  the  prognosis.  Quite  as  large  a 
percentage  of  rich  as  of  poor  die.  The  personal  constitution  and  habits  are 
of  some  importance.  I  have  repeatedly  been  impressed  with  the  unhappy 
effect  upon  the  course  and  result  of  typhoid  fever  produced  by  exertit.n  or 
exposure  during  the  early  days  of  the  Mtack.  The  curious  fa(rt  that  those 
who  are  in  delicate  health  from  i)revious  disease  or  other  causes  do  not 
suffer  more  in  attacks  of  typhoid  fever  than  those  in  vigorous  health  may 
be  partly  explained  by  the  fact  that  the  former  yield  to  the  early  symp- 
toms and  place  themselves  promptly  under  treatment,  while  the  latter  are 
too  apt  to  persist  in  their  usual  occupation  until  utterly  exhausted.  Mur- 
chison  and  others  maintain  that  the  strong  and  n.bust  and  those  of  large 
muscular  development  more  readily  succumb.  It  is  well  known  (hat  the 
corpulent  are  particularlv  liable  to  die  from  it.  This  is  due  to  the  fact 
that  the  fever  runs  unusually  high  in  them,  and  that  the  high  f.MMp.-ra- 
ture  induces  degenerative  changes  in  their  tissues  with  unusual  .-asc.  in 
persons  of  intemperate  habits  or  in  those  with  gouty  or  rmal  alVcctums  the 
disease  is  more  apt  to  terminate  fi.tally.  In  th<.se  ..f  a  nervous  tcn,p,.ra.n.nt 
manv  of  the  svmptoms  are  liable  to  be  worse.  Thr  s.isccptd.d.ty  ol  I  ,.- 
system  and  the  intcusitv  of  the  virus  have  mor..  to  do  with  th-  gravity  ol  ih. 
case  than  any  other  infl"uences.     It  is  a  n.attcr  of  general  agreenu-nt  that  young 


112  TYPHOID    FEVER. 

persons  who  have  recently  moved  into  large  towns  where  more  or  less  typhoid 
is  always  i)resent  are  specially  liable  to  the  disease  and  in  an  aggravated  form. 
On  the  other  hand,  most  fatal  outbreaks  occur  in  isolated  and  healthy  families 
or  communities,  owing  to  accidental  infection  of  the  locality.  When  typhoid 
fever  attacks  pregnant  women  abortion  nearly  always  follows,  and  the  danger 
of  a  fatal  result  is  considerable.  The  existence  of  organic  heart  disease,  em- 
physema, cirrhosis  of  the  liver,  or  Bright's  disease  greatly  increases  the  gravity 
of  typhoid  fever. 

The  prominence  of  certain  symptoms  has  an  important  bearing  upon  the 
proo-nosis.  The  higher  the  temperature  goes  and  the  more  persistently  it 
remains  elevated,  the  greater  the  danger  to  life  becomes.  This  is,  however, 
onlv  a  general  rule.  High  temperature  may  often  be  borne  well  for  a  con- 
siderable time,  provided  severe  nervous  symptoms  do  not  attend  it.  When 
the  morning  remissions  are  slight  and  brief  the  prognosis  is  worse.  An 
inverted  temperature  curve,  with  the  morning  temperature  higher  than  that 
of  the  evening,  is  also  unfavorable.  On  the  other  hand,  the  earlier  in  the 
attack  the  morning  fall  begins  to  become  steadily  more  marked,  the  more 
favorable  is  the  prognosis.  A  sudden  fall  of  temperature,  if  accompanied 
with  a  corresponding  fall  in  pulse-rate  and  improvement  in  general  symp- 
toms, may  denote  the  crisis  of  an  abortive  attack  and  be  followed  by 
convalescence.  If,  however,  the  sudden  fall  be  attended  with  marked 
depression  of  strength,  it  may  denote  the  approach  of  collapse,  especially 
from  copious  hsemorrhage. 

A  temporary  descent  in  the  temperature  curve  and  improvement  in  general 
condition  during  the  second  or  third  week,  followed  by  a  return  of  the  fever 
and  other  symptoms  in  aggravated  form,  is  an  unfavorable  occurrence,  and  the 
attack  is  apt  to  end  fatally.  I  have  repeatedly  seen  bitter  disappointment  result 
from  this  delusive  lull  in  the  symptoms.  I  am  inclined  to  agree  with  Lacaze 
that  the  appearance  of  sudamina  in  the  third  week  in  severe  cases  is  apt  to  be 
a  favorable  sign,  and  that  the  temperature  often  falls  within  a  few  days  subse- 
quently. Most  writers,  however,  do  not  believe  that  sudamina  possess  any 
prognostic  value. 

A  pulse  of  over  120 — except  in  children  or  under  excitement — is  always  a 
sign  of  cardiac  weakness.  This  is  particularly  true  if  the  pulse  be  at  the  same 
time  feeble.  Liebermeister's  statistics  show  that  the  more  rapid  the  pulse-rate 
the  greater  the  mortality  becomes.  Of  12  patients  in  whom  it  attained  a  rapidity 
of  over  150,  11  died.  The  character  of  the  first  sound  of  the  heart  is  also 
of  great  prognostic  importance.  The  more  valvular  its  quality  and  the  more 
feeble  the  cardiac  impulse,  the  graver  the  prognosis.  Naturally,  the  earlier 
the  pulse  and  the  heart-sounds  show  signs  of  weakness,  the  more  unfavorable 
is  it.  Dicrotism  is  so  characteristic  of  the  pulse  in  typhoid  fever  that  unless 
associated  with  great  softness  and  weakness  it  is  not  especially  significant  of 
danger. 

The  early  developuient  of  nervous  symptoms  is  unfavorable.  The  presence 
of  coma  or  of  wild  delirium  is  a  grave  indication.     Low  muttering  delirium. 


TREA  TMEXT.  1 1  ?, 

with  tremor,  occurring  early  in  the  attack,  also  is  an  indication  that  the  case  is 
a  very  severe  one.  According  to  Zonner,  the  degree  of  delirium  is  to  some 
extent  a  measure  of  the  gravity  of  the  infection,  thougli  care  must  be  taken 
to  recognize  those  cases  where  the  excitcxl  delirium  is  hysteroidal  in  nature  and 
unattended  by  other  symptoms  of  special  danger.  Coma  vigil,  carphologia, 
subsultus,  rigidity,  general  convulsions,  ])rotracted  hiccough,  early  inconti- 
nence or  retention  of  urine,  early  incontinence  of  fjeces,  insomnia,  great  pros- 
tration early  in  the  disease,  great  tymiwnitcs  and  abdominal  pain,  a  dry  brown 
tongue,  severe  diarrhoea,  severe  intestinal  hremorrhagc,  vomiting  late  in  the 
attack,  and  the  occurrence  of  peritonitis  from  any  source  or  the  development 
of  any  other  complication,  of  course  add  to  the  seriousness  of  the  disease  to  a 
greater  or  less  extent. 

Eegarding  the  influence  on  prognosis  caused  by  the  association  of  other 
infectious  fevers  with  typhoid  fever,  it  is  sufficient  to  say  that  the  coexistence 
of  malarial  poison  does  not  seem  to  add  to  the  danger,  but  that  most  cases  of 
the  malarial  form  of  typhoid  are  of  favorable  type. 

Treatment. — Prophylaxis. — Typhoid  fever  is  certainly  to  a  large  extent  a 
preventable  disease.  Produced  as  it  is  by  a  specific  germ,  it  is  self-evident 
that  the  objects  of  prophylaxis  are  to  destroy  the  germ  wherever  known  to 
exist,  and  to  adopt  every  precaution  against  its  admission  to  the  svstcm. 

In  the  care  of  each  case  of  typhoid  fever  the  frecal  discharges,  which  con- 
tain the  virus  in  abundance,  must  be  thoroughly  disinfected  and  properly  dis- 
posed of.  Special  reference  is  here  made  to  the  careful  directions  given  for  this 
purpose  in  the  section  on  Disinfection  in  the  article  HvcaENK.  The  disinfected 
discharges  should  be  emptied  into  ])rivies  or  water-closets,  but  never  upon  the 
open  ground.  In  rural  districts  they  may  be  buried  in  the  earth  at  points 
remote  from  the  supply  of  drinking-water.  Equal  attention  must  be  given 
to  the  disinfection  of  the  body-linen  of  the  sick,  the  bed-clothing,  the  mat- 
tresses, and  the  furniture  of  the  sick-room. 

While  thus  endeavoring  to  prevent  extension  of  the  disease,  it  is  essential  to 
make  careful  search  for  the  source  of  infecti(m  in  each  individual  case.  The 
remarks  under  the  head  of  Etiology  in  this  article,  as  well  as  the  article  on 
Hygiene,  may  be  consulted  with  advantage.  The  driidving- water  and  the 
milk-supply  offer  themselves  as  the  most  probable  sources  of  infection.  In 
large  cities  it  is  for  the  most  part  impossible  to  follow  uj)  the  investigation. 
In  localized  outbreaks,  in  small  towns,  or  in  rural  districts,  on  the  other  Jiand, 
we  know  with  what  admirable  results  such  examinations  have  been  pin-sued. 
Grave  defects,  leadins:  to  contamination  of  these  necessarv  articles  (»f  universal 
consumption,  are  detected  whose  correction  will  avert  fntiu-e  trouble.  If  in 
any  large  community  typhoid  fever  is  habitually  |)revalent  to  a  greater  i^v  less 
degree,  it  may  be  accepted  as  highly  damaging  evidence  against  the  drainage, 
sewerage,  water-supply,  or  milk-supj)ly.  During  the  existeii.e  of  an  attack 
of  typhoid  fever  it  is  desirable  that  both  the  water  and  milk  should  be  I)(.ile<l 
before  being  ingested.  Defects  in  drainage  and  in  house-sewerage  ;ire  less 
likely  to  lead  to  this  than  to  some  other  infections.     In  w<-ll-sewered  heii^.s  the 

Vol,.  I.— 8 


114  TYPHOID    FEVER. 

chief  danger  to  health  connected  with  the  system  occurs  when  the  fixtures  have 
been  unused  for  two  or  three  months  and  the  traps  and  interior  of  the  pipes  have 
become  dry,  so  as  to  give  off  dust-particles  which  are  carried  into  the  rooms. 
It  is  unwise  to  disturb  existing  arrangements  about  a  house  during  the  course 
of  a  case  of  typhoid.  After  its  conclusion  careful  examination  must  be  made 
of  the  entire  drainage  and  sewerage  systems.  In  large  towns  with  public 
sewers  this  inquiry  is  necessarily  limited  to  the  iiuternal  fixtures  and  to  the 
connection  with  the  sewers.  In  rural  districts  a  wider  field  of  investigation 
must  be  covered. 

Treatment  of  the  Attack.  — The  general  management  of  a  case  of  typhoid 
fever  involves  many  details,  careful  attention  to  which  does  much  to  determine 
the  favorable  result  of  the  case.  In  tKis  disease  it  is  pre-eminently  true  that 
a  good  nurse  without  any  doctor  is  better  than  the  best  doctor  without  a  good 
nurse.  A  caretaker  of  intelligence,  preferably  a  trained  nurse,  should  be 
€arly  placed  in  charge,  in  order  that  the  careful  written  instructions  of  the 
physician  niciy  be  accurately  and  systematically  carried  out. 

The  sick-room  should  be  as  large  and  airy  as  possible.  When  practicable 
it  should  have  a  sunny  exposure.  If  there  is  a  better  room  available  than 
that  in  which  the  patient  first  takes  to  bed,  a  transfer  should  be  made 
promptly  before  the  more  serious  stages  of  the  disease  are  reached.  The 
course  of  the  disease  is  so  long,  and  the  result  so  largely  depends  on  the 
maintenance  of  vitality,  that  these  questions  assume  great  importance.  The 
room  should  be  kept  scrupulously  clean  and  well  ventilated.  It  is,  however, 
a  grievous  mistake  to  suppose  that,  on  account  of  the  infectious  nature  of  the 
disease,  strong  draughts  may  safely  be  permitted.  There  are  remissions  in  the 
fever  with  relaxation  of  the  surface,  and  congestions  or  increased  catarrhal 
irritation  may  readily  be  induced  if  the  patient  be  not  carefully  protected. 
The  use  of  screens  is  to  be  advised,  both  to  guard  against  currents  of  air  and 
to  aid  in  softening  the  light  in  the  room. 

The  bed  should  be  neither  too  hard  nor  too  soft.  A  feather  mattress  is  to 
be  avoided  :  a  woven-wire  mattress  covered  with  one  of  hair  forms  one  of  the 
best  beds.  A  rubber  cloth  should  be  spread  beneath  the  sheet.  Since  much 
care  is  required  to  avoid  the  formation  of  bed-sores,  the  sheet  must  be  kept 
smooth,  and  in  the  later  stages  of  severe  cases  a  water-bed  may  be  used  with 
great  advantage. 

Complete  rest  in  bed  is  essential.  From  the  first  hour  that  the  suspicion 
of  typhoid  fever  arises  the  patient  must  be  put  to  bed  and  kept  there  until 
the  close  of  the  case.  The  earlier  this  is  done  the  better  the  prognosis.  Not 
only  in  hosjiital  practice,  but  in  private,  we  meet  many  cases  where  the  patient 
has  persisted  in  his  occupation  or  liis  pleasures,  or  where  journeys  have  been 
undertaken,  during  the  first  week  of  the  fever,  and  the  effect  upon  the  course 
and  result  of  the  disease  is  very  bad. 

The  use  of  the  bed-pan  and  urinal  should  be  insisted  upon  from  the  start. 
Many  patients  find  difficulty  at  first  in  emptying  the  bladder  or  bowels  in  the 
recumbent  position,  but  as  a  rule  they  soon  acquire  the  power.     Cases  are  met 


TREATMEyT.  115 

with,  however,  where  the  effort  continues  fruitless,  and  causes  such  excitement 
and  annoyance  that  it  is  necessary  to  have  the  patient  lit\ed  on  the  commode 
at  the  side  of  the  bed.  I  have  seen  this  necessity  arise  most  frequently  with 
young  women,  and  by  the  use  of  proper  care  no  ill  effects  have  followed  in 
any  case. 

In  cases  marked  with  extreme  restlessness  and  insomnia  it  sometimes 
does  good  to  have  a  second  bed  prepared,  and  to  move  the  patient  to  it  for  a 
portion  of  each  day.  A  transfer  to  another  chamber  may  exert  a  soothing 
and  happy   influence. 

The  diet  is  also  of  great  importance.  It  should  be,  U\^m  the  start,  liipiid 
and  easily  digestible.  Milk  generally  answers  the  re(piircments  better  than 
any  other  article.  In  many  cases  it  serves  as  the  only  article  of  food  that 
need  be  given  throughout  the  course  of  the  disease,  or  at  least  constitutes  the 
basis  of  the  diet.  It  ensures  the  ingestion  of  considerable  rupiid  ;  it  is  readily 
digested  by  most  persons  when  taken  as  an  exclusive  diet ;  its  favorable  effect 
in  gastro-intestinal  catarrh,  always  present  in  typhoid,  is  well  known  ;  its 
relations  to  hepatic  and  renal  activity  are  favorable.  From  one  and  a  half  to 
two  quarts  is  the  proper  amount  for  an  adult  during  twenty-four  hours,  pro- 
vided it  does  not  disagree.  It  siiould  be  given  in  divided  quantities  every 
two  to  three  hours  during  the  twenty-four  hours.  Care  must  be  taken  not  to 
administer  more  milk  than  can  be  readily  digested.  This  can  be  determined 
by  watching  for  symptoms  of  gastric  indigestion  or  for  an  increase  of  diarrhtea 
or  the  presence  of  curds  and  of  fat-globules  in  the  stools. 

Great  harm  may  be  done  by  forcing  excessive  amounts  of  milk  and  other 
liquid  nourishment  upon  fever  patients,  as  though  their  debility  demanded, 
and  their  inability  to  resist  justified,  its  administration.  It  should  not  be 
necessary  to  insist  on  the  fact  that  food  must  be  digested  in  fever  just  as  in 
health  ;  that  the  secretions  of  the  stomach  and  the  tone  of  its  muscidar  coat 
are  much  impaired,  especially  in  typhoid  ;  and  that  all  ingesta  in  excess  of  the 
digestive  power  are  doubly  injurious. 

The  milk  mav  be  siven  raw  or  boiled,  hot  or  cold,  iced,  peptonized,  mixetl 
with  lime-water  or  aerated  water,  according  to  the  case.  It  is  a  mistake,  how- 
ever, to  consider  milk  the  only  suitable  article  of  diet.  It  is,  as  has  already 
been  said,  the  most  generally  acceptable  food  in  typhoid  fever,  and  especially 
when  a  decided  tendency  to  diarrlirea  exists.  lint  in  st.me  instances  it  tends 
to  produce  constipation,  and  may  even  form  such  hard  masses  of  curd  in  the 
stomach  and  intestine  that  it  becomes  practically  one  (.i"  the  most  s<.lid  <.f 
foods.  If  these  difficulties  cannot  be  overcome  by  peptonizing  it  or  by  niixing 
it  with  lime-water,  it  may  be  necessary  to  substitut<>  some  other  Ibrm  of 
nourishment.  Again,  the  repugnance  of  ihe  i)atient  to  milU  may  necessitate 
a  change  of  diet.  In  such  cases  buttermilk,  whey,  or  kumnyss  may  be  ..f 
value.  Broths  or  soups  of  mutton,  beef,  chicken,  veal,  oysters,  or  <Iarns  are 
often  useful.  They  may  contain  a  small  (inantity  of  barley  or  riee.  While 
of  egg  mixed  with  watir  or  with  stinuilants  is  vahinMe  at  titnes.  as  is  beef- 
juice  or  some  of  the  various  prej)arations  of  beef  on   the  market. 


116  TYPHOID    FEVER. 

Whether  the  patient  shall  be  aroused  for  nourishment  during  the  night 
depends  largely  upon  circumstances.  If  the  case  is  mild,  it  may  not  be  neces- 
sary to  do  so.  If,  on  the  other  hand,  there  is  little  sound  sleep,  but  the  con- 
stant presence  of  somnolence,  he  will  probably  need  the  food,  and  awakening 
him  will  do  no  harm.  If,  again,  the  patient  has  been  suifering  from  insomnia, 
and  is  enjoying  the  first  refreshing  sound  sleep,  it  can  scarcely  ever  be  proper 
to  arouse  him  either  for  food  or  medicine.  The  tact  and  skill  of  a  nurse  are 
in  nothing  better  shown  than  in  dealing  with  the  sleep  and  the  nourishment 
of  fever  patients. 

The  patient  should  be  convalescent  for  at  least  ten  days  before  a  gradual 
return  to  solid  food  is  commenced.  I  am  aware  that  some  excellent  observers 
sanction  the  use  of  small  quantities  of  semi-solid  or  solid  food,  but  my  own 
experience  is  wholly  opposed  to  it.  I  have  repeatedly  observed  unpleasant  or 
even  alarming  symptoms  so  closely  connected  with  the  ingestion  of  even  a 
minute  amount  of  such  food  that  it  was  impossible  not  to  regard  them  as 
directly  caused  by  it. 

In  addition  to  the  liquid  food,  water  should  be  freely  given.  The  hebe- 
tude often  blunts  the  perception  of  thirst,  so  that  the  patient  may  not  ask  for 
water,  and  yet  will  take  it  greedily  if  offered.  It  is  important,  therefore,  that 
small  amounts  be  given  at  short  intervals.  On  the  other  hand,  it  is  essen- 
tial that  the  stomach  should  not  be  so  flushed  with  cold  water  as  to  weaken 
digestion.  Carbonated  water  or  cracked  ice  is  often  an  agreeable  change. 
Very  weak  iced  tea  may  be  allowed  in  small  quantities.  Water  acidulated 
with  lemon-juice  or  with  a  few  drops  of  dilute  phosphoric  acid  is  grateful, 
and  may  be  given  if  there  be  no  diarrhoea. 

The  question  of  administering  alcohol  comes  up  for  discussion  in  every  case 
of  typhoid  fever.  It  must  be  stated  at  the  outset  that  in  mild,  uncomplicated 
cases,  especially  in  young,  healthy,  and  temperate  subjects,  stimulants  are  not 
needed  so  long  as  the  disease  is  following  its  typical  course.  Here  as  else- 
where alcohol  should  be  avoided  when  not  absolutely  demanded,  both  because 
it  may  irritate  or  disagree  and  because  its  use  may  tend  to  establish  a  habit. 
There  is,  however,  such  a  dangerous  tendency  to  exhaustion  from  various 
causes  that  in  a  majority  of  cases  more  or  less  alcohol  is  required  sooner  or 
later  in  the  course  of  the  disease. 

The  indications  which  call  for  its  use  are,  in  the  first  place,  an  inability  to 
administer  enough  food.  There  are  cases  where,  owing  to  repugnance  or  to 
nausea,  it  seems  impossible  to  have  enough  food  taken  to  support  life  until  the 
disease  abates.  Under  such  circumstances  small  amounts  of  stimulants,  such 
as  brandy  or  whiskey  in  carbonated  water  or  in  milk,  or  dry  champagne,  not 
only  are  assimilated  as  food,  but  aid  in  maintaining  the  circulation  till  the 
crisis  is  past.  There  are  also  prej)arations  which,  like  the  various  liquid 
peptonoids,  are  both  nutritious  and  sufficiently  stimulating.  Again,  the 
existence  of  high  temperature  nearly  always  makes  it  necessary  to  stimulate 
the  patient.  Nervous  exhaustion  and  heart  failure  are  urgently  impending, 
and  while  ]>ropcr  antipyretic  measures  are  the  rational  treatment,  it  is  neces- 


TRKA  TMEXT.  1  ]  7 

sary  to  use  alcohol  for  immediate  effect.  The  heart  suffers  so  seriously  in 
typhoid  from  failure  of  innervation,  from  changes  in  the  muscuhu-  tissue,  and 
from  protracted  reflex  irritation  that  a  weak,  small,  compressible,  rapid  pulse, 
M-itli  impaired  cardiac  impulse  and  systolic  sound,  is  a  frequent  indication  for 
alcohol.  Other  remedies  may  be,  as  we  shall  see,  recpiiral,  but  alcohol^  can- 
not be  dispensed  with  safely.  The  development  of  the  typical  tyj)hoid  state, 
with  profound  dulness,  tremor,  dry,  brown  tongue  and  sordes,  weaU  jMdse, 
and  shallow,  rapid  breathing,  whether  associated  with  very  high  temperature 
or  not,  expresses  so  much  nervous  exhaustion  that  stimulation  is  called  for. 

It  is  necessary  to  give  alcohol  in  the  serious  complications  of  tvpjioid,  such  as 
pneumonia,  pleurisy,  hiemorrhage,  and  severe  bronchitis  or  diarrluoa.  Patients 
over  forty  years  of  age,  even  of  previously  temperate  habits,  and  younger  ones 
who  have  been  intemperate,  had  better  receive  small  quantities  of  alcohol 
early  ;  and  the  dose  should  be  increased  more  or  less  rapidly  as  rcfjuired.  It 
will  be  seen,  therefore,  from  the  above  indications,  that  although  alcohol  is 
not  to  be  ordered  as  a  mere  matter  of  routine,  it  is  called  ibr  in  most  cases, 
and  we  must  be  ready  to  give  it  as  soon  as,  and  in  such  amounts  as,  recpiired. 

The  amount  to  be  administered  will  vary  with  the  needs  of  the  case. 
Unless  the  symptoms  are  urgent  it  is  well  to  begin  with  small  and  well- 
diluted  doses.  As  the  case  advances,  from  2  to  6  ounces  of  whiskey  daily 
may  be  called  a  moderate  amount ;  8  to  12  ounces  daily  is  not  too  nuich  for 
severe  adynamic  or  complicated  cases ;  and  even  more  than  this,  up  to  an 
ounce  hourly,  may  be  absolutely  required  for  days  in  succession  to  tide  a 
patient  over  a  critical  period. 

When  alcohol  is  ordered  or  when  the  amount  given  is  increased,  it  must  be 
considered  a  tentative  measure,  as  in  the  case  of  any  other  remedy.  I  am  con- 
vinced that  under  the  routine  practice  of  excessive  stinuilation  in  vogue  until 
recently  the  symptoms  of  alcoholic  over-action  were  often  mistaken  for 
advancing  debility  and  regarded  as  an  indication  for  still  more  free  stinuila- 
tion. If  delirium  grows  less,  the  pulse  stronger,  and  the  tongue  less  dry 
under  the  use  of  alcohol,  the  remedy  is  doing  good  ;  but  if  these  symptoms 
become  aggravated,  the  question  should  be  entertained  whether  too  uiuch 
alcohol  is  not  being  given. 

Probably  the  most  convenient  and  reliable  form  of  stiuuilaut  is  wliisk(y  or 
brandy,  its  greater  strength  making  the  dt)se  smaller  and  more  manageable. 
It  may  be  given  in  milk  or,  when  this  is  not  borne  well,  iu  water.  Some- 
times it  is  well  to  change  for  a  time  to  clKUupagne,  sherry,  claret,  or  otlier 

wine. 

Undoubtedly,  one  of  the  most  important  indications,  wliich  nmst  be  met  in 
the  great  majority  of  cases  of  typhoid  fever,  is  (hat  for  reduction  of  Icuipera- 
ture.  It  is  "true  there  are  cases  which  run  so  iiiil'l  a  course,  llir  Hv(  r  not 
rising  at  any  time  above  102°  F.,  that  this  (|uestioM  Anrs  not  liav  to  be  <-on- 
sidered.  There  are  other  and  more  rare  cases  where  liigl.  t.m|MiMtun-  is  carricHl 
without  apparent  inconvenience.  I  have  seen  th.Mlaily  maxinuMu  at  lOo"  F.  for 
ten  davs  in  succession  in  (he  case  of  a  young  woman  who  had  at  n.>  time  .-ither 


118  TYPHOID    FEVER. 

delirium  or  cardiac  weakness,  and  who  made  a  rapid  and  complete  recovery 
though  no  antipyretic  treatment  was  used.  This  only  shows  that  the  pyrexia 
of  typhoid  fever  is  a  highly  complex  condition,  and  that  high  temperature 
may  occasionally  persist,  owing  to  some  peculiar  nervous  disturbance,  without 
the  serious  results  usually  consequent.  Even  when  a  temperature  of  103°  or 
104°  F.  is  apparently  unattended  with  damage  to  the  brain  or  heart,  it  must 
be  watched  with  incessant  anxiety,  because  alarming  symptoms  may  appear 
most  unexpectedly.  To  what  point  may  fever  be  allowed  to  go  safely  in 
typhoid  without  interference,  and  have  we  any  means  at  our  disposal  by 
which  it  can  be  surely  and  safely  reduced  if  it  threaten  to  overstep  this 
limit  ?  Our  knowledge  of  the  natural  history  of  typhoid  shows  it  to  be  a 
self-limited  disease  which  tends  to  recovery  in  the  great  majority  of  cases, 
though  the  temperature  reaches  102.5°  or  103.5°  F.  more  or  less  frequently  in 
the  course  of  average  cases.  But  the  normal  mortality  of  the  disease,  if 
allowed  to  run  its  course  simply  with  proper  food  and  good  care,  is  altogether 
too  high  to  be  satisfactory  ;  and  it  is  being  more  and  more  clearly  made  out 
that  a  large  proportion  of  this  mortality  comes  directly  or  indirectly  from 
the  baleful  influence  of  the  pyrexia.  This  statement  has  been  confirmed  con- 
clusively by  the  remarkable  results  obtained  in  a  large  series  of  cases  by  reso- 
lutely kee{)ing  the  temperature  down  below  the  lowest  degree  above  mentioned 
(102.5°  F.).  The  only  way  in  which  this  can  be  done  safely  and  effectually  is 
by  the  external  use  of  cold  water,  and  hence  to-day  hydrotherapy  is  an  almost 
constant  feature  in  our  treatment  of  typhoid. 

There  are  various  modes  of  a])plying  it,  which  vary  in  their  efficiency  and 
value,  including  repeated  spongings  of  the  surface ;  the  ice-cap  to  the  head; 
the  cold-water  pack  ;  cold  afiPusion  ;  Leiter's  tubes ;  the  graduated  bath  ;  the 
strict  Brand  method  of  cold-water  bathing.  In  mild  and  even  in  ordinary 
cases  sponging  the  entire  surface  of  the  body  with  cool  water  as  often  as  the 
temperature  in  the  mouth  reaches  102°  F.,  is  distinctly  valuable.  A  little 
vinegar  or  alcohol  may  be  added  to  the  water,  which  may  be  cold  (50°-70°  F.) 
or  cool  (70°-80°  F.)  according  to  the  less  or  greater  degree  of  fever ;  and  the 
sponging  may  be  kept  up  for  ten  minutes  or  more,  and  be  repeated  as  often  as 
every  two  hours.  Friction  and  gentle  kneading  of  the  surface  should  be  com- 
bined with  it.  The  temperature  may  be  temporarily  reduced  from  1°  to  1.5°  F. 
in  this  way.  As  a  rule,  it  promptly  rises  again,  but  the  process  is  agreeable 
and  not  fatiguing  to  the  patient.  A  thin  rubber  bag  or  bladder  filled  with 
cracked  ice  may  be  applied  to  the  head  at  the  same  time,  and  kej)t  in  place 
much  longer.  Even  when  the  fever  is  not  high,  but  nervous  excitement  is 
marked,  this  may  be  used  with  good  effect. 

The  cold  pack  is  a  much  more  powerful  antipyretic,  and  is  applicable  even 
when  the  temperature  is  104°  or  105°  F.  The  bed  should  be  protected  by 
a  riibi)er  cloth,  and  the  patient,  with  his  body-clothing  removed,  wrapped 
in  a  sheet  wet  with  cold  water.  The  surface  is  then  rubbed  briskly  through 
the  sheet,  and  from  time  to  time  cold  water  is  sprinkled  freely  over  the  sheet 
so  that  it  shall  be  kept  wet  and  cold.     By  using  ice-water,  even  hyperpyrexia, 


TREATMEXT.  IIU 

104.5°  F.  or  above,  may  be  dealt  with  etfectively  in  this  way  ;  but  the  process 
is  tedious  and  troublesome.  The  recommendation  to  use  friction  durino;  the 
pack  must  not  be  overlooked.  Cold  affusion  possesses  no  advantage  over  the 
cold  pack,  and  is  rather  more  troublesome  to  cai  ly  out  etFectivclv.  Both  of 
these  methods  are  inferior  to  the  cold  bath  in  certainty  of  action  and  durabil- 
ity of  effect. 

Leiter's  tubes  were  originally  made  of  flexible  metal,  but  now  mucli  more 
conveniently  of  rubber.  The  most  valuable  forms  are  those  for  application  to 
the  abdomen  and  trunk  and  to  the  head.  A  vessel  containing  icc-watcr  is 
placed  at  a  slight  elevation  above  the  bed  :  one  end  of  the  tube  is  introduced, 
and,  the 'flow  having  been  started  by  syphon  action,  the  water  runs  contirui- 
ously  through  the  coil,  and  escapes  by  the  other  end  of  the  tube  into  a 
receptacle  below  the  bed.  One  great  merit  of  this  simple  api)aratus  is  that 
it  may  be  kept  in  operation  for  hours  at  a  time  with  no  attention  save  the 
occasional  filling  and  emptying  of  fhe  respective  vessels.  In  my  own  experi- 
ence I  have  not  found  these  tubes  adequate  to  cojie  with  very  high  fever,  but 
they  are  valuable  adjuvants  and  are  sufficient  for  many  ordinary  cases. 

In  the  graduated  bath  the  patient  is  placed  in  water  of  about  90°  F.,  which 
is  then  cooled  down  to  70°  or  even  lower.  This  form  of  bath  must  be  con- 
tinued longer  and  its  results  are  less  reliable  than  when  the  water  is  cold  from 
the  start.  It  has  the  advantage  that  the  shock  to  the  patient  is  not  so  great : 
it  is  therefore  especially  suited  to  children,  to  old  persons,  and  to  greatly  debili- 
tated cases. 

All  of  these  modes  of  supplying  cold  externally  are  useful  and  have  their 
respective  places,  but  from  none  of  them  can  sncli  results  be  obtained  as  from 
the  svstematic  use  of  cold  baths  in  precise  accordance  with  the  method  advo- 
cated by  Brand.  His  original  publication  in  1861  led  Ziemssen,  Liebermeisfer, 
and  others  to  take  up  the  subject,  and  gradually  hydrotherapy  in  typhoiil  fever 
became  generally  recognized.  Currie  in  the  last  century  was  the  pioneer  in  this 
field.  Hiram  Carson  in  this  country  has  for  many  years  bravely  advocated  its 
claims,  but  the  medical  mind  was  not  ready  and  the  recommendations  lacked 
strict  scientific  method.  Herein  is  the  immense  credit  of  I'raud,  and  it  must 
be  admitted  that  no  such  results  have  ever  been  achieved  as  ar(>  now  reported 
by  many  observers  who  have  followed  his  directions  implicitly. 

The  Brand  method  consists  in  the  systematic  employment  of  general  cold 
baths  with  frictions  whenever  the  temperatiu-e  of  the  patient  reaches  a  certain 
elevation.  A  large  bath-tub,  nun-able  on  rollers,  is  kept  half  lull  of  water  of 
65°  to  70°  F.,  and  is  rolled  to  the  edge  of  tlie  bed  when  needed.  As  often  a-^  th<- 
temperature,  taken  every  three  hours  in  the  mouth  or  nclmn,  is  over  1()2.'2°  F., 
the  i)atient  receives  a  bath  lasting  fifteen  to  twenty  minutes.  His  clothes 
are  removed,  and  he  is  covered  with  a  sheet  or  arrayed  in  a  ihin  iini>Iiu  or 
linen  garment  specially  adapted  for  the  puri)ose.  lb'  is  then  careluily  assiste<l 
from  the  bed  to  the  edge  of  the  tul),  or,  if  not  able  to  assist  himself,  is  lift.'d 
bodily  into  the  water  by  the  attendants,  if  it  seems  advisable  a  small  amount 
of  stimulant  is  given.  "  Some  cold  water  is  now  poiuvd  over  his  head  as  he 


120  TYPHOID    FEVER. 

gets  into  the  bath  in  order  to  diminish  the  shock,  and  he  is  then  submerged 
in  the  bath  up  to  the  neck.  The  liead  can  rest  conveniently  upon  a  rubber 
cushion.  Dnring  the  whole  period  of  immersion  he  should  be  briskly  rubbed 
through  the  sheet  and  cold  water  poured  on  his  head  at  intervals.  This  fric- 
tion and  affusion,  together  with  a  second  dose  of  stimulant,  aids  largely  to 
prevent  or  check  the  tendency  to  chill  and  cyanosis  which  otherwise  develops 
at  the  end  of  about  ten  minutes.  After  the  bath  the  wet  linen  is  quickly 
removed,  and  the  patient  is  placed  in  bed,  wrapped  in  a  sheet,  and  covered 
with  a  blanket  without  friction  or  any  drying  of  the  skin.  A  stimulant  can 
be  given  after  the  bath,  and  the  temperature,  preferably  in  the  rectum,  should 
be  taken.  The  accompanying  chart  (see  Fig.  9)  illustrates  well  the  immense 
superiority  of  general  cold  baths  over  even  the  most  through  sponging. 

Brand's  last  statistics  are  really  remarkable.  He  tabulated  1223  cases 
treated  according  to  his  method  by  himself  and  a  few  other  clinicians.  Only 
12  deaths  occurred — a  mortality  of  1  per -cent!  All  of  the  fatal  cases  were 
in  individuals  who  did  not  come  under  treatment  until  after  the  fifth  day  of 
the  disease.  He  claims  as  a  result  of  thirty  years'  experience  that  every  case 
of  typhoid  fever  will  recover  in  which  his  method  of  treatment  is  commenced 
before  the  fifth  day. 

Brand's  method  has  been  widely  used  in  Germany  for  some  years.  In 
France  it  has  not  found  general  acceptance,  although  Glenard's  results  at 
Lvons  have  been  excellent.  In  England  the  method  has  not  yet  been  largely 
adopted.  In  America  the  results  of  all  those  who  have  given  the  treatment  a 
fair  trial  have  been  most  encouraging,  although  the  number  of  cases  is  not  yet 
sufficiently  large  to  justify  absolute  conclusions.  Hare  of  Australia  reports 
797  cases  with  a  mortality  of  7  per  cent. 

The  percentages  of  recoveries  in  general  have  not  been  so  good  as  in  the 
remarkable  statistics  recently  published  by  Brand.  It  must  be  remembered, 
however,  that  in  many  series  of  cases  some  of  the  patients  have  not  been  treated 
in  strict  accordance  with  his  method  nor  from  a  sufficiently  early  day.  The 
fact  remains,  in  spite  of  this,  that  no  other  mode  of  treatment  has  ever  yielded 
such  good  results  on  a  large  scale.  Not  only  is  the  mortality  lessened,  but  the 
whole  course  of  the  disease  seems  to  be  rendered  milder.  The  mind  remains 
more  clear,  without  the  development  of  stupor ;  sleeplessness  and  excitement 
are  also  less.  The  typical  typhoid  state  is  less  frequently  observed  than  under 
otlier  plans  of  treatment.  Nor  are  there  any  serious  risks  or  disadvantages 
connected  with  it.  It  has  been  asserted  that  the  treatment  by  cold  baths 
increases  the  tendency  to  intestinal  haemorrhage,  but  this  has  not  been  sub- 
stantiated. Liebermeister  reports  that  of  861  cases  treated  without  cold 
bathing,  8.4  per  cent,  suffered  from  such  haemorrhages,  while  they  occurred  in 
only  6.2  per  cent,  of  882  cases  subjected  to  bathing.  It  has  also  been  claimed 
tiiat  relapses  and  severe  complications  are  more  common  under  the  cold-water 
treatment,  but  there  is  no  reliable  evidence  in  support  of  this  assertion. 

Experience  has  already  shown  that  Brand's  method  is  very  generally 
applicable.     Excellent  results  have  been  reported  in  cases  occurring  in  infancy 


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122  TYPHOID   FEVER. 

and  childhood.  Not  only  are  such  complications  as  pneumonia  and  bronchitis 
not  induced  by  cold  baths,  but  it  has  been  shown  that  their  existence  does  not 
contraindicate  this  mode  of  treatment.  Pregnancy  likewise  is  no  contra- 
indication. 

Enough  has  been  said  to  show  that  there  has  been  placed  in  our  hands  by 
Brand  a  mode  of  treating  typhoid  fever  of  great  simplicity  and  value.  The 
question  remains  as  to  its  limitations  and  as  to  when  it  should  be  insisted 
upon.  In  the  first  place,  it  is  as  yet  a  very  difficult,  and  often  an  impossible, 
thing  to  secure  its  adoption  in  private  practice.  If  it  is  to  be  employed,  it 
should  be  with  the  rigid  observance  of  every  detail  as  above  described.  This 
certainly  seems  to  many  a  harsh  course  of  treatment  to  pursue,  and  the  patients 
often  complain  bitterly  of  it.  Not  rarely,  however,  the  relief  obtained  after  a 
few  baths  is  so  great  that  the  repugnance  to  it  disappears. 

The  difficulty  of  securing  a  suitable  movable  bath-tub  at  short  notice  and 
on  reasonable  terms  has  been  a  serious  obstacle.  It  will  be  found,  however, 
that  any  leading  druggist  will  cheerfully  co-operate,  so  that  a  tub  with  proper 
attendants  may  be  available  at  all  hours  and  at  reasonable  rent.  Dr.  Wilmer 
R.  Batt  of  Philadelphia  has  recently  devised  a  portable  tub  which  is  all  that 
can  be  desired  in  point  of  compactness  and  convenience.  It  is  obvious  that 
no  community  can  with  propriety  be  without  this  invaluable  resource  in  the 
treatment  of  the  numerous  acute   infectious  diseases. 

In  cases  which  do  not  come  under  our  treatment  until  a  comparatively  late 
period,  as  happens  frequently  in  hospitals  and  less  commonly  in  private  prac- 
tice, this  method  is  less  successful,  as  is  urgently  represented  by  Brand  him- 
self, than  when  adopted  before  the  fifth  day  of  the  disease. 

In  mild  cases  the  fever  may  not  rise  sufficiently  high  at  any  time  to  sug- 
gest any  more  powerful  mode  of  applying  cold  water  than  by  repeated  spong- 
ing. If,  however,  the  temperature  rises  to  102°  in  the  axilla  or  102,2°  in 
the  mouth  or  rectum,  the  Brand  method  should  be  adopted  if  practicable, 
or  the  use  of  Leiter's  tubes,  with  the  ice-cap,  repeated  sponging,  and,  if  neces- 
sary, the  cold  pack,  should  be  instituted.  This  is  the  more  urgent  in  propor- 
tion as  the  temperature  remains  at  or  about  the  maximum  for  a  greater  num- 
ber of  hours.  Let  it  be  remembered  that  under  such  circumstances,  even 
though  serious  cerebral  or  cardiac  symptoms  may  not  be  present,  they  are 
liable  to  appear  abruptly  and  unexpectedly,  so  that  the  case  will  speedily 
assume  a  highly  dangerous  position. 

In  extremely  nervous  cases  or  in  elderly  or  much  debilitated  subjects  the 
milder  forms  of  hydrotherapy  are  preferable.  The  actual  existence  of  intes- 
tinal haemorrhage  or  of  peritonitis  precludes  cold-water  bathing. 

In  addition  to  the  external  use  of  cold  water  we  have  other  antipyretic 
remedies  that  may  be  used  in  conjunction  with  hydrotherapy,  or  even,  in  cer- 
tain cases,  to  its  exclusion,  A  warning  word  must  be  spoken  as  to  many  of 
them,  for  serious  harm  is  often  done  by  the  excessive  use  of  drugs  which  pos- 
sess the  power  of  reducing  temperature,  under  the  mistaken  notion  that  this 
result  alone  is  sufficient  proof  of  their  value  in  the  case.     It  must  never  be 


TREA  TMENT.  1 23 

forgotten  that  the  mere  lowering  of  temperature  by  such  means  is  not  neces- 
sarily an  improvement  in  the  febrile  process,  and  that  the  drugs  which  are  pow- 
erful enough  to  effect  it  are  sure  to  possess  other  activities  which  may  be  harm- 
ful. In  short,  it  is  to  be  borne  in  mind  that  it  is  the  patient,  and  not  the  fever 
alone,  we  are  called  on  to  treat.  Happily,  a  reaction  has  set  in  against  the 
practice,  which  grew  out  of  the  recognition  of  the  dangers  of  pyrexia  and  the 
possession  of  drugs  of  great  antipyretic  power,  of  hammering  down,  and  of 
trying  to  keep  down,  the  temperature  by  large,  and  if  necessary  by  larger,  doses 
of  such  remedies. 

Antipyrine,  phenacetin,  and  acctanilid  are  the  most  powerful  and  reliable 
drugs  of  this  class.     Not  only  do  they  reduce  fever  temperature  remarkal>ly, 
but  they  are  usually  w'ell  borne  by  the  stomach  and  they  often  exert  a  decid- 
edly tranquillizing  action.     Upon  their  first  introduction  the  natural  mistake 
was  made  of  giving  them  in  doses  far  too  large  and  frequent,  so  that  serious 
depression  of  strength,  and  even  fatal  collapse,  followed  in  many   instance.s. 
Patients  with  typhoid  fever  are  often  peculiarly  susceptible  to  the  action  of 
these  substances.     This  is  true  throughout  the  course  of  the  disease,  but  ]iar- 
ticnlarly  so    in    the  later  stages,  when  great  variations  in    temperature  nat- 
urally occur.     It  is  not  so  much  that  these  drugs  are  directly  depressing  to  the 
heart,  for  thev  rarely  cause  cardiac  symptoms  when  given  in  afebrile  condi- 
tions.    Even  here,  however,  I  have  observed  not  a  few  cases  of  extreme  sus- 
ceptibility to  their  depressing  action.     But  it  appears  that  in  fever  they  aflt'ect 
the  nerve-centres,  so  that  an  artificial  crisis  is  produced,  and,  as  in  all  crises, 
danger  of  severe  depression,  and  even  of  collapse,  arises.     With  this  danger 
clearly  in  mind  the  proper  cautious  use  of  these  remedies  is  of  great  service  in 
certain  cases.    They  are  nol  required  in  the  mild  form  with  moderate  fever  :  the 
question  as  to  their  use  arises  when  the  temperature  reaches  or  passes  103°  F. 
If  hydrotherapy  is  to  be  used  systematically,  only  occasional  doses,  if  any,  of 
these  powerful  antipyretics  will  be  required.    The  amount  given  should  always 
be  small.     Five  grains  of  antipyrine  and  less  of  phenacetin  or  acctanilid  is  as 
large  a  dose  as  should  be  given.     If  no  effect  is  produced  it  may  i)c  rcpeatctl 
in  the  course  of  an  hour.     The  object  should  not  be  to  cause  a  great  ii.Il   in 
temperature:  it  is  enough  if  a  reduction  of  one  or  one  and  a  half  degrees  is 
secured.     It  sometimes  happens  that  this  reduction  lasts  a  considerabk^  time, 
80  that  only  a  few  doses  at  long  intervals  are  required  ;  and   it   is  in  such 
instances  that  the  happy  effects  of  the  remedy  are  conspicuous,      if  the  tem- 
perature promptlv  rises  again   to  the  former  jx.int,  T  am  totally  opposed  to 
pushing  the  use  of  anv  remedy  of  this  class.     Ehrlieh  and  others  have  f.sted 
the  plan  of  keeping  the  fever  constantly  low  by  the  continuous  administration 
of  small  doses  of  these  drugs,  but  the  results  were  not  satisfactory  eitluM-  a>  to 
the  duration  or  the  mortalitv  of  the  cases  so  treated.  ^ 

The  use  of  quinine  in  tvphoid  fever  has  been  excessive,  and  yet    it  is  of 
service  in  many  cases  as  a  tonic  rather  than  as  an  antipyret.e.      1  lien-  are  so 
many  more  powerful  and  reliable  means  of  redn.ing  ten.p.ratnre  than   by 
colossal  doses  of  quinine  (20  to  40  grains  in  the  evemng,  as  udv.se.1  by  L.eb.T- 


124  TYPHOID    FEVER. 

meister,  so  that  the  full  efFect  of  the  drug  may  be  exerted  at  the  time  of  the  usual 
morning  remission)  that  it  is  now  rarely  used  for  this  purpose.  If  in  any  case 
with  high  fever  hydrotherapy  cannot  be  used,  if  antipyrine  or  its  analogues 
would  be  too  depressing,  and  if  the  stomach  be  not  irritable,  antipyretic  doses 
of  quinine  could  be  given.  It  is,  however,  in  moderate  doses,  4  to  8  grains 
in  the  twenty-four  hours,  that  it  is  of  most  general  utility.  It  may  be  given 
in  soft,  freshly-made  pills,  in  capsules,  or  in  solution  with  mineral  acids.  If 
there  l)e  tlie  least  reason  to  suspect  that  it  irritates  the  stomach  or  favors  diar- 
i-lioea,  its  administration  in  larger  amount  by  suppository  or  enema  should  at 
once  be  substituted.  In  ordinary  cases  which  are  pursuing  a  normal  course  it 
need  not  be  given  until  marked  debility  begins  to  show  itself. 

The  preparations  of  salicylic  acid  will  often  exert  a  powerful  antipyretic 
action,  but  in  adequate  doses  they  affect  the  head  as  unpleasantly  as  does 
(piinine,  are  apt  to  disorder  the  stomach,  and  are  probably  depressing  to  the 
heart. 

In  the  moderate  fever  of  mild  or  ordinary  cases  aconite  in  small  doses  may 
be  given  safely  and  with  pleasant  effect.  One  drop  of  the  tincture  of  the  root, 
with  or  without  a  small  amount  of  citrate  of  potassium,  solution  of  acetate  of 
ammonium,  or  spirit  of  nitrous  ether,  may  be  given  every  hour  or  two  for 
five  or  six  doses  from  noon  onward. 

Digitalis  is  a  drug  about  whose  value  in  fever  I  have  much  doubt.  I 
am  clear  it  should  not  be  given  in  large  doses  for  its  antipyretic  effect.  The 
onlv  indications  for  its  use  are  to  be  found  in  the  state  of  the  heart's  action 
and  the  pulse. 

Having  considered  the  general  care  of  the  patient,  the  diet,  and  the  indica- 
tions for  the  use  of  stimulants  and  for  the  control  of  the  fever,  we  have  met 
the  questions  which  arise  in  every  case  of  typhoid  fever.  We  have  seen  that 
it  is  only  in  the  mild  cases  that  an  expectant  plan  of  treatment  can  be  pursued, 
because  the  scientific  use  of  antipyretic  measures  constitutes  a  definite  treat- 
ment, and  we  have  now  learned  that  by  this  method  far  better  results  are 
secured  than  by  allowing  the  disease  to  run  its  normal  course.  It  constantly 
haj)pens,  however,  that  special  indications  present  themselves  which  call  for 
additional  medication.  It  cannot  be  too  strongly  urged,  however,  that  no  single 
dose  of  medicine  should  be  ordered  unless  with  a  definite  and  well-recognized 
purpose.  Tiie  symptoms  are  numerous  and  complex,  so  that  many  suggestions 
for  medicati(m  offer  themselves :  the  patient  is  dull  and  acquiescent,  so  that 
remedies  are  taken  for  the  most  part  without  opposition  ;  care  must  be  con- 
stantly observed  lest  by  degrees  drug  is  added  to  drug  until  opportunities  for 
rest  are  curtailed  and  the  digestive  power  of  the  stomach  is  damaged. 

The  catarrlial  and  ulcerative  lesions  of  the  gastro-intestinal  mucous  mem- 
brane are  constant  in  greater  or  less  degree.  It  is  true  they  are  part  of  a 
specific  process,  and  therefore  much  less  amenable  to  treatment  than  if  idio- 
pathic. There  is  much  evidence,  however,  that  these  lesions  can  be  favorably 
affected  by  suitable  remedies  if  administered  from  a  very  early  period  of  the 
disease.     It  is  obvious  that  if  this  can  be  done  the  secretions  will  be  improved, 


TREA  TME^T.  1  _>;-) 

digestion  will  be  assisted,  and  intestinal  asepsis  promoted  indirootlv.  It  is 
doubtful,  indeed,  whether  any  of  the  so-called  antise})ties  which  have  been 
recommended  in  typhoid  fever  can  be  given  in  sufficient  amount  to  disinfect 
the  whole  mass  of  intestinal  contents ;  and  it  is  not  improbable  that  their  sur- 
face action  may  account  for  a  considerable  part  of  whatever  good  tiiey  do. 
But,  upon  the  whole,  it  seems  desirable  that  a  remedy  of  this  class  shall  be 
given  in  all  cases  of  the  disease,  due  care  being  taken  to  select  one  which  is 
adapted  to  the  condition  of  the  stomach  and  bowels.  The  large  nnnd)er  of 
such  remedies  recommended  is  of  itself  sufficient  to  prove  that  no  one  is  the 
most  available  in  all  instances.  The  list  from  which  choice  may  be  matle  is 
a  large  one,  so  that  the  special  indication  of  each  may  be  met. 

Among  them  may  be  mentioned  calomel,  nitrate  of  silver,  the  mineral 
acids,  turpentine,  naphthalin,  iodine  and  carbolic  acid,  chlorine-water,  thymol, 
salol,  iodoform.  It  is  of  course  understood  that  only  one  remedy  of  this  class 
should  be  used  at  one  time. 

My  own  decided  preference  has  for  years  been  for  nitrate  of  silver,  which  I 
give  in  every  case  from  the  first  hour  that  the  nature  of  the  disease  is  sus- 
pected. It  is  given  purely  for  its  surface  action,  just  as  it  would  be  used  in  a 
case  of  idiopathic  gastro-intestinal  catarrh.  It  is  administered  in  conjunction 
with  appropriate  antipyretic  treatment,  and  it  is  usually  comjiatible  with  any 
other  remedy  required  for  special  indications.  Its  use  is  contimied  through- 
out the  entire  course  of  the  case,  and  as  much  as  twenty-five  grains  may  be 
given  to  an  adult  without  the  least  fear  of  causing  discoloration  of  the  skin. 
In  case  symptoms  arise  which  suggest  another  remedy  of  this  class,  the 
change  should  be  made  promptly.  If  the  stomach  is  irritable,  the  following 
solution  may  be  used  : 

I^.  Argenti  nitratis,  gr.  i.j ; 

Aquae  destillat.,  f.^iij  vcl  iv. 

M.  Ft.  sol. 
Sig.  A  teaspoonful  on  an  empty  stomach  every  four  or  six  hours..     One  op 

two  drops  of  deodorized  tincture  of  opium  may  be  added  to  each 
dose. 

Usually  silver  is  best  given  in  pill  form,  according  to  this  formula  : 

'Sf.  Argenti  nitratis,  g'"-  vj  ; 

Ext.  opii, 
Ext.  belladonnas,  aa.  gr.  ij  ; 

Mannse,  4-  •"'• 

Misce  et  div.  in  pil.  xxiv. 
Sig.  A  pill  tiiree  times  daily  soon  after  food. 

If  diarrhoea  develop,  the  belladonna  may  be  omKtcd  an<l  the  <.pium  ho 
increased  ;  if  constipation  be  present,  the  opium  n.ny  be  dropped  an.l  ext. 
nuc.  vomicae  gr.  \  be  added  to  each   pdl. 


126  TYPHOID    FEVER. 

jNIy  own  belief  is  that  this  remedy  so  administered  is  a  safe  and  useful  part 
of  the  regular  treatment  of  typhoid  fever,  and  that  when  begun  early  and 
continued  judiciously  it  helps  in  some  degree  to  prevent  the  developmemt 
of  serious  .symptoms  and  intestinal  complications.  This  is  not  only  my  own 
experience,  but  that  of  many  of  my  colleagues  who  have  adopted  this  treat- 
ment. Many  ridicule  the  notion  that  any  good  can  be  done  by  such  small 
doses  of  so  unstable  a  salt ;  but  the  clinical  evidence,  both  in  this  disease  and 
in  gastro-intestinal  catarrhs,  deserves  consideration,  and  we  know*that  we  are 
dealing  with  a  mucous  membrane  in  a  state  of  such  morbid  irritability  that 
the  ingestion  of  even  a  minute  amount  of  unsuitable  food  may  induce  violent 
symptoms. 

The  mineral  acids,  muriatic,  nitro-muriatic,  sulphurous,  and  phosphoric,  are 
all  valuable,  both  for  surface  action  and  as  antiseptics.  They  are  most  useful 
when  the  tongue  has  a  heavy  yellow  coating,  but  is  not  dry ;  when  the 
abdomen  is  not  greatly  distended  and  the  bowels  are  quiet ;  and  when  there 
is  considerable  thirst.  They  should  be  given  in  moderate  doses,  freely  diluted, 
at  intervals  of  three  or  four  hours. 

Turpentine  is,  in  my  judgment,  of  unquestionable  value  in  certain  cases. 
Not  only  is  it  a  powerful  antiseptic  and  a  good  stimulant,  but  its  action  on  the 
mucous  membrane  in  properly  selected  cases  is  excellent.  The  symptoms 
which  call  for  its  use  in  preference  to  the  other  remedies  of  this  class  are 
a  dry,  brown  tongue  with  tendency  to  sordes ;  abdominal  distension  without 
much  diarrhoea ;  considerable  bronchial  catarrh,  and  cardiac  and  muscular 
weakness.  I  venture  to  believe  that  no  one  can  have  given  this  remedy  in 
suitable  form  and  dose  under  the  above  conditions  without  sometimes  observ- 
ing, as  I  have  done  repeatedly,  such  prompt  and  positive  improvement  in  all 
the  symptoms  as  could  only  be  attributed  to  its  action.  It  may  be  used  accord- 
ing to  this  formula  : 

^.  Ol.  terebinthinse,  fgiij  ; 
Pulv.  acacise, 

Sacchari,  ad.  q.  s. ; 

Sp.  lavandulse  comp.,  f^iij  ; 

Aquae,  q.  s.  ad  fsvj. 
Ft.  mist.  sec.  artem. 
Sig.  One  to  two  teaspoonfuls  in  a  little  water  every  three  hours. 

If  the  stomach  be  irritable,  it  is  well  to  reduce  the  dose  of  turpentine  and 
to  add  to  each  dose  one  or  two  drops  of  deodorized  laudanum. 

In  place  of  the  oil  of  turpentine  a  capsule  containing  from  two  to  four 
grains  of  white  turpentine  may  be  given  every  three  hours. 

Calomel  has  often  been  used  as  an  intestinal  antiseptic,  and  it  has  been 
claimed,  without  any  sufficient  grounds,  that  the  disease  may  be  aborted  by  it 
when  given  in  small  doses  day  after  day.  The  only  purpose  for  which  it  is 
to  be  recommended  is,  however,  as  a  sedative  to  the  stomach  and  as  one  of  the 


TEE  A  TMEXT.  127 


mildest  aud  most  manageable  of  laxatives:  so  that  if,  either  at  the  beirinnintr 
of  the  case  or  at  any  time  during  its  course,  a  laxative  is  indicated,  fractional 
doses  of  calomel  (gr.  ^  every  two  hours)  may  be  used  until  a  single  move- 
ment is  secured.  The  view  that  the  condition  of  the  intestine  or  the  course 
of  the  disease  may  be  influenced  favorably  by  purgative  doses  of  calomel  or 
of  salines  is  totally  opposed  to  my  own  experience  and  opinion. 

A  mixture  of  two  parts  of  tincture  of  iodine  with  one  part  of  carbolic  acid 
has  also  been  recommended  to  produce  intestinal  antisepsis,  and  has  found 
some  acceptance.  One  to  three  drops  of  the  mixture  may  be  given  three  times 
a  day.  Yeo  recommends  chlorine-water  and  quinine  for  the  same  purpose. 
Murchison  years  ago,  and  Schonleiu  before  him,  spoke  highly  of  chlorine  in 
this  disease.  Naphthalin  has  been  recommended  by  Rosenthal  and  others  fol- 
lowing him.  Very  excellent  results  were  reported  by  Wolf,  the  disease  seem- 
ing to#in  an  abortive  course  in  16  out  of  100  patients.  The  dose  should  be 
from  15  to  60  grains  a  day.  During  its  administration  the  urine  becomes 
very  dark  in  color,  but  this  is  claimed  to  be  a  matter  of  no  significance. 

The  employment  of  thymol  has  been  urged  very  strongly  by  certain 
writers.  Henry  is  even  convinced  that  the  typical  symptoms  of  typhoid  fever 
will  rarely  develop  if  the  drug  be  administered  during  the  first  week  of  the 
attack.  It  should  be  given  in  pills  freshly  made  with  medicinal  soap.  One 
or  two  pills,  each  containing  2|  grains,  may  be  given  every  three  hours. 
Sufficient  water  should  be  swallowed  after  each  pill  to  ensure  its  passage  out 
of  the  oesophagus,  as  otherwise  disagreeable  burning  may  result.  Salol  has 
been  advocated  by  a  number  of  writers,  and  undoubtedly  possesses  decided 
power  in  producing  intestinal  antisepsis.  Other  derivatives  of  salicin  have 
likewise  been  recommended  for  the  purpose,  as  have  also  iodoform,  the  sul- 
phites, sulphocarbolate  of  zinc,  a-naphthol,  /9-naphthol,  and  corrosive  subli- 
mate. 

Treatment  of  Special  Symptoms  and  Complkatiom. — As  would  be  expectetl, 
some  of  the  special  symptoms  or  complications  in  ty]ihoid  fever  usually  re- 
quire treatment  directed  particularly  toward  them.  Fortunately,  it  will  be 
found  that  in  proportion  as  rigid  rest  and  diet  are  insisted  ui)on,  ami  as  proi)er 
measures  for  the  control  of  fever  and  for  the  treatment  of  the  intestinal  condition 
are  adopted  at  the  outset  of  the  disease,  the  subsequent  development  of  grave 
symptoms  or  of  serious  complications  will  be  correspondingly  infrequent. 

Headache  is  best  managed  by  strict  quiet  and  darkening  of  the  room. 
Cold  may  be  applied  to  the  head,  or  menthol,  chloroform  liniment,  camphor, 
or  the  like  may  be  used  locally.  If  these  fiiil,  potassium  bromide  may  allord 
relief,  or  small  doses  of  antipyrine  (gr.  v)  or  of  the  elVerveseing  granulatcnl 
antipyrine  and  sodium  salicylate  (.^ij,  containing  4  grains  of  each)  uv  of  phe- 
nacetin  (gr.  iij)  mav  be  given.  Finally,  a  sui)posit..ry  of  ext.  opium  gr.  },,  with 
quinine,  5  or's  grains,  may  be  used  if  the  pain  be  not  alh.yecl  by  other  means. 
Insomnia  sometimes  demands  active  treatment  in  order  to  prevent  nervous 
exhaustion.  Codeia  (gr.  \  to  J),  sulphonal  (gr.  x  or  xv),  p..t:.ssiun.  bromide 
(gr.   xv)  with  chloral   hydrate  (gr.  yj),  iiave  i)roved  the  most  usehd   in   my 


128  TYPHOID   FEVER. 

experience.  An  enema  of  deodorized  laudanum  or  a  suppository  of  the  ex- 
tracts of  opium  and  hyoscyamus  may  be  required,  or  even  a  hypodermic 
injection  of  morphine  (gr.  J  or  \)  with  a  minute  dose  of  hydrobromate  of 
hyoscine  (gr.  yl^  or  ■^). 

Delirium  and  somnolence  are  so  often  associated  with  high  fever  that  hydro- 
therapy, a])plied  as  already  described,  is  generally  essential  and  most  valuable 
in  their  treatment.  Suppositories  containing  asafoetida  and  quinine,  gr.  x  each, 
may  be  given  two  or  three  times  daily.  If  the  delirium  be  active  or  violent, 
small  doses  of  hyoscine  (gr.  yi-j  to  •^)  may  act  admirably.  Large  doses  may 
prove  depressing.  Codeia  is  often  useful,  quieting  delirious  excitement  with- 
out inducing  stupor.  Potassium  bromide  with  elixir  of  valerianate  of  ammo- 
nium is  of  value,  especially  in  cases  of  hysteroidal  type.  When  the  delirium 
tends  to  be  of  the  low  muttering  type,  camphor  or  musk  may  be  of  service. 
The  latter  is  of  very  uncertain  action.  To  be  of  any  benefit  it  must  be  of  the 
best  quality  and  be  given  in  large  doses,  and  unless  it  acts  promptly  it  is  useless 
to  continue  it.  Carbonate  of  ammonium  is  much  less  used  now  than  formerly, 
but  may  occasionally  be  given  with  advantage  in  this  condition  in  the  dose  of 
gr.  v  every  two  or  three  hours  in  the  form  of  emulsion.  Ice  to  the  head  is 
here  also  useful.  A  hot  mustard  foot-bath  may  induce  relaxation  and  quiet. 
Blistering  the  nape  of  the  neck,  or  even  the  shaved  scalp,  has  been  recom- 
mended, and  frequently  practised  when  the  cerebral  symptoms  are  aggravated. 
It  never  seems  to  me  proper  to  use  this  painful  measure,  and  T  fear  it  usually 
does  more  harm  than  good. 

Patients  with  typhoid  fever  always  require  close  watching,  but  when 
delirium  is  present  they  must  not  be  left  alone  for  an  instant.  They  fre- 
quently endeavor  to  leave  the  bed,  and  will  even  struggle  violently  to  do  so. 
Before  resorting  to  mechanical  restraint  all  the  resources  of  kind  and  skilled 
nursing  must  be  exhausted.  It  may  be  judicious  to  let  the  patient  rise  to  the 
sitting  posture  or  sit  on  the  edge  of  the  bed  for  a  few  minutes,  after  which  his 
delirious  restlessness  may  be  for  the  time  allayed,  and  he  will  sink  back  on 
the  bed  in  a  more  quiet  state.  I  have  even  been  led  in  rare  cases  to  allow  the 
patient  to  rise  to  his  feet  and  to  be  placed  in  an  easy-chair  close  to  the  bed, 
and  have  observed  good  results  to  follow.  If  restraint  be  unavoidable,  it  is 
best  applied  by  passing  a  sheet  over  the  body  and  fastening  it  under  the  bed. 

Vomiting  at  the  outset  of  the  disease  should  be  treated  by  withholding  food 
and  medicine,  save  fractional  doses  of  calomel,  alone  or  combined  with  bis- 
muth, or  minute  doses  of  nitrate  of  silver,  of  creasote,  or  of  dilute  hydro- 
cyanic acid.  If  the  stomach  be  very  irritable,  a  mild  emetic  may  be  useful. 
When  vomiting  occurs  later,  it  usually  shows  that  the  food  or  medicine  dis- 
agrees. The  milk  should  at  once  be  reduced  in  amount,  and  be  diluted  with 
lime-water  or  carbonated  water,  or  milk  may  be  temporarily  suspended,  and 
small  amounts  of  dry  champagne,  liquid  peptonoids,  or  light  broths  be  admin- 
istered. Very  hot  water  taken  in  spoonful  doses,  small  pieces  of  ice  swal- 
lowed, or  some  of  the  remedies  above  mentioned  mav  be  tried.  Even  if 
vomiting  occur  only  once  a  day  or  every  other  day,  it  shows  that  the  stomach 


TREATMENT.  ,  12!t 

is  iu  a  state  of  continuous  irritation,  ami  a  ciianire  of  food  or  of  medicine,  or 
of  both,  is  required. 

Diarrhoea  is  one  of  the  symptoms  which  most  frequently  demands  attention. 
Even  if  the  bowels  are  quiet,  so  that  movements  must  be  encouraged,  a  little 
carelessness  in  feeding  or  medication  is  apt  to  bring  on  looseness.  Actual  con- 
stipation is  comparatively  rare,  though  more  common  than  usual  in  some  epi- 
demics. If  the  bowels  are  quiet,  therefore,  it  is  better  to  use  a  simple  enema 
every  other  day.  If  there  is  looseness  it  is  necessary  to  decide  by  the  numi)er 
and  size  of  the  movements  whether  anvthino;  shall  be  done  to  check  it.  As  a 
rule,  it  is  not  necessary  to  interfere  if  the  movements  do  not  exceed  two  in 
number  daily,  and  are  not  very  large  and  liquid.  The  stools  should  be  in- 
spected in  order  to  determine  whether  undigested  food  is  being  passed,  and  if 
so,  the  diet  should  be  modified  and  restricted  before  recourse  is  had  to  reme- 
dies to  check  the  looseness.  Beef  tea  or  other  strong  meat  broths,  for  instance, 
may  increase  the  tendency  to  looseness ;  and  when  this  exists  milk  ])roperly 
diluted  and  in  suitable  amounts  should  be  depended  on  exclusively  in  most 
cases.  The  pills  of  nitrate  of  silver  Mith  oj)ium  are  very  efficient  in  con- 
trolling diarrhoea.  Small  doses  of  acetate  of  lead  with  opium  are  also  valu- 
able.    The  following  may  be  used  with  advantage : 

I^.  Bismuthi  subnitratis,  3iij  ; 

Pepsin,  saccharat.,  3ij  ; 

Morphimie  sulph.,  g''- j* 

M,  et  div.  in  chart,  xx. 
Sig.  One  powder  every  three  or  four  hours. 

It  is,  as  a  rule,  judicious  to  suspend  other  medication  while  using  any  of 
these  astringents ;  but  if  the  latter  are  not  effective,  or  if  it  seems  essential  to 
continue  other  remedies  by  the  mouth,  the  diarrhoea  should  be  controlled  by 
enemata  of  deodorized  laudanum  in  starch-water  or  by  such  suppositories  as — 


I^.  Pulv.  iodoformi. 

gr.  XXX  ; 

Acid,  tannici. 

3j; 

Ext.  opii  aq., 
Ol.  theobroma?. 

gr.  V  ; 
q.  s. 

M.  Ft.  mist,  et  div.  suppos.  xx. 

Sig. 
Or, 

Use  as  required. 

I|i.  Plumbi  acetatis, 

Ai ; 

Ext.  opii, 

gr.  V  ; 

Ol.  theobroma?. 

q.  s. 

M.  et  div.  in  siqipos.  xx. 

Sig. 

Use  as  required. 

On  the  other  hand,  constipation  may  demand  treatmenl.      W'v  \\\\\r  m-cu 
that  the  existence  of  ulceration,  even  so  deej)  as  eventually  to  cause  perfora- 

VoL.  I.— 9 


130  TYPHOID    FEVER. 

tion,  is  cunsistent  with  a  torpid  and  constipated  state  of  the  bowel  through- 
out the  course  of  the  disease.  Modification  of  the  diet  may  effect  a  change. 
Occasional  short  courses  of  small  doses  of  calomel  or  of  a  mild  saline  may  be 
required,  but,  on  the  whole,  small  enemata  are  to  be  preferred  to  laxatives.  I 
have  found  tlie  simple  white-wheat  gluten  suppositories  sufficient  in  some  cases, 
or  glycerin  in  the  form  of  suppository  or  of  enema  will  be  more  active. 

Tympanites  may  become  so  extreme  as  to  cause  great  distress  and  to  add 
materially  to  the  danger  of  the  case  by  pushing  up  the  diaphragm  and  embar- 
rassino-  the  heart  and  lungs.  It  is  most  serious  Avhen  paretic  in  nature 
and  due  to  degenerative  changes  and  weakness  of  the  muscles  of  the  abdomi- 
nal and  intestinal  walls  and  of  the  diaphragm.  In  other  cases  it  is  due  to 
excessive  development  of  gases  in  the  intestine  from  decomposition  of  the  food 
and  morbid  secretions.  Under  the  latter  circumstances  more  rigid  restriction 
of  tiie  food,  small,  frequently  repeated  doses  of  such  antiseptic  remedies  as 
turpentine,  thymol,  or  naphthalin,  mild  laxative  doses  of  calomel  or  of  castor 
oil  with  turpentine  in  emulsion,  and  the  external  use  of  turpentine  stupes, 
are  to  be  considered.  When  the  distension  seems  largely  due  to  weakness 
of  the  muscles,  an  increase  in  the  amount  of  stimulus  may  relieve  it;  and  with 
this  may  be  joined  full  doses  of  strychnine  by  the  mouth  or  injected  hypoder- 
mically  into  the  abdominal  walls.  Enemata  containing  turpentine  or  asafoetida 
are  also  valuable,  or,  as  a  last  resort,  a  soft  rectal  tube  may  be  introduced  very 
carefully  as  far  as  possible  into  the  colon. 

Abdominal  pain  often  accompanies  great  tympanites.  It  usually  is  only 
the  result  of  the  excessive  distension,  but  occasionally  it  is  so  acute  and  intense 
as  to  indicate  the  existence  of  localized  peritonitis.  It  is  indeed  not  improb- 
able that  in  many  cases  of  extreme  tympanites  there  are  patches  of  plastic  peri- 
tonitis which  further  aid  in  inducing  paresis  of  the  intestinal  walls.  In  the 
case  of  the  lad  referred  to  on  page  (iQ  the  fact  that  the  extraordinary  and 
prolonged  distension  was  thus  caused  was  shown  by  the  subsequent  presence 
of  a  large  indurated  mass,  doubtless  composed  of  enlarged  glands,  agglutinated 
coils  of  intestines,  and  plastic  exudation,  which  required  many  months  to  dis- 
apj)ear. 

Peritonitis,  unless  of  circumscribed  character,  is  a  very  fatal  complication, 
whether  it  result  from  perforation  of  the  bowel  or  from  extension  of  inflam- 
mation from  the  base  of  deep  ulcers.  It  is  to  be  treated  by  the  most  absolute 
rest,  on  a  water-bed  if  possible;  by  opiates  by  the  mouth  or  hypodermically, 
in  such  doses  as  to  maintain  a  proper  constitutional  effect ;  by  cold  to  the  abdo- 
men ;  and  by  the  smallest  possible  amount  of  food  and  drink,  and  at  first  only 
cracked  ice  and  dilute  stimulants.  Strychnine  may  be  given  with  morphine 
hyj)odermically.  If  collapse  is  threatened,  external  heat  and  ether  hypoder- 
mically are  to  be  tried.  The  whole  effort  must  be  to  maintain  life  and  to  keep 
the  bowels  quiet,  so  that  if  perforation  have  occurred  the  development  of 
adhesions  may  be  favored.  The  same  treatment  is  appropriate  if  peritonitis  has 
arisen  without  perforation  ;  and  it  is  always  presumable  if  recovery  ensues  that 
such  has  been  the  case,  though  the  possibility  of  recovery  after  perforation  is  not 


TR  EA  TMEXr.  1  n  1 

to  be  absolutely  denied.  It  is  questionable  whether  laparotomy  is  ever  justifiable 
in  typhoid  fever,  and  whether  the  patient's  chanees  for  life  are  not  better  without 
it.  The  statistics  of  the  operation  during  the  course  of  the  disease  are  most 
unfavorable ;  and  it  is  only  when,  during  convalescence,  peritonitis  suddenly 
develops  with  the  symptoms  of  perforation  tiiat  I  should  sanction  its  per- 
formance. 

Intestinal  haemorrhage  presents  most  difficult  (piestions  in  treatment.  If  it 
be  small  in  amount,  without  apparent  tendency  to  recur,  and  the  general 
symptoms  show  no  .sign  of  depression  or  shock,  it  is  unnecessary  to  pay  any 
attention  to  it.  Harm  may  be  done  by  instituting  at  once  active  treatment 
w^ith  irritating  and  depressing  astringents.  Cold  to  the  abdomen  may,  iiow- 
ever,  always  be  applied  with  safety  and  advantage  in  the  form  of  Leiter's 
tubes  or  the  ice-bag.  In  every  case  of  intestinal  hix?morrhao;c  absolute  rest 
must  be  insisted  upon,  a  folded  cloth  being  substituted  for  the  bed-pan,  so  that 
even  the  lifting  of  the  nates  may  be  avoided.  If  the  haemorrhage  be  larger, 
if  the  blood  be  dark  as  though  coming  from  high  up  in  the  intestines,  and  if 
there  be  any  evidence  of  depression  or  shock,  in  addition  to  the  external  use 
of  cold  small  pieces  of  ice  may  be  swallowed  and  a  small  enema  of  ct)ld,  or 
even  of  iced,  water  may  be  used.  Hypodermic  injections  of  ergotin  in  large 
doses  form  in  my  judgment  the  most  reliable  haemostatic  treatment.  Acetate 
of  lead  and  opium  or  aromatic  sulphuric  or  gallic  acid  may  be  given  by  the 
mouth.  I  have  known  very  large  doses  of  oil  of  turpentine  (f.sj  in  emulsion 
in  thirty-six  hours)  given  with  marked  success  in  a  case  under  the  care  of 
Dr.  Batt,  where  six  larse  luemorrhages  on  the  twenty-first  and  twenty-second 
davs  had  induced  most  alarming  collapse,  with  a  fall  of  temperature  from 
105°  to  97°.  Stimulants  should  be  given  freely  if  collapse  threatens,  but 
ether  and  strychnine  hypodermically  are  the  most  promjit  and  powerful 
remedies  to  induce  reaction.  Recovery  may  occur  from  an  ap])arcntly  mori- 
bund condition,  so  that  we  should  never  relax  our  efforts  in  this  condition  so 
long  as  life  is  still  present. 

If  the  loss  of  blood  has  been  great,  transfusion  of  blood  and  iiitrav.nous 
injections  of  a  warm  solution  of  sodium  chloride  iiave  been  used  with  occa- 
sional success.  Wiien  a  haemorrhagic  diathesis  develops,  as  it  may  do  late  in 
the  course  of  grave  cases,  the  tincture  of  tiie  chloride  of  iron  and  turpentine 
have  seemed  to  me  most  useful. 

Epistaxis  profuse  enough  to  demand  interference  is  unusual.  In  exhausted 
conditions,  however,  even  small  losses  of  blood  are  dangerous.  The  best  treat- 
ment is  bv  ice  to  the  nose,  forehead,  and  nape  of  the  neck  ;  ergot,  turpentine, 
or  oil  of  erigeron  internally  ;  insufflations  of  alum  or  tannic  acid  ;  and,  linally, 
as  a  last  resort,  by  plugging  the  narcs. 

Heart  failure  is  chiefly  to  be  guarded  against  by  systematic  reduction  of  the 
temperature  and  by  the  use  of  alcoholic  stinudants  and  of  strychnin.'  in  lull 
doses.  In  an  emergency  either  alcohol  <.r  ether  may  be  given  hypo.lcrmicaIly. 
Tincture  of  digitalis  in'small  doses,  5  <„•  (i  .In.ps  every  two  or  thnr  hours,  or 
tincture  of  strophanthus  in  equal  amounts,  may  be  usefid  ;  but  I  have  seen  no 


132  TYPHOID    FEVER. 

o-ood  result  from  large  doses  of  these  remedies  in  the  heart  failure  of  fever. 
On  the  contrary,  harm  may  result  from  pushing  their  administration  freely. 
Nitro-glycerin  (gr.  y-J-^  to  ■^)  or  caffeine  (gr.  ij,  repeated  at  short  intervals)  is 
more  valuable.  Either  may  be  given  by  the  mouth  or  hypodermic-ally,  as 
may  also  camphor  dissolved  in  olive  oil.  I  would  lay  especial  stress  on  the 
systematic  use  of  strychnine  in  moderate  doses  when  there  is  a  tendency  to 
cardiac  or  respiratory  failure,  and  in  large  and  oft-repeated  doses  hypodermi- 
callv  when  such  failure  is  imminent  or  actual.  Reference  may  be  made  to  the 
case  reported  on  page  88  as  showing  to  what  extent  and  with  what  happy 
result  its  use  may  be  pushed. 

Hypostatic  congestion  of  the  lungs,  extensive  bronchial  catarrh  and  ]ki1- 
monarv  oedema,  and  hypostatic  pneumonia  are  all  apt  to  be  associated  with  high 
temperature  and  a  tendency  to  cardiac  and  respiratory  failure.  We  have  seen 
that  hvdrotherapy  neither  tends  to  induce  these  complications  nor  is  contra- 
indicated  by  their  existence.  Frequent  changing  of  the  position  of  the  patient 
is  useful  in  prophylaxis  and  in  treatment.  Dry  cups  may  be  applied  repeat- 
edly to  the  chest  posteriorly,  and  I  have  even  used  a  few  wet  cups  with  good 
effect.  Frequent  deep  inspirations  or  inhalations  of  oxygen  are  also  of  value. 
Finally,  strychnine  and  quinine  in  solution  with  mineral  acids  (as  in  the  fol- 
lowing formula)  may  be  given  with  great  advantage  : 

I^.  Quininse  sulph.,  3j  ; 

Strychninse,  gr.  j  ; 

Acid,  muriatic,  diluti,  f^iij  ; 

Tr.  cardamomi  comp.,  f^iij  ; 

Aquse  purse,  q.  s.  ad  f^v. — M. 
Ft.  sol.  et  filt. 
Sig.  A  teaspoonful  in  water  every  four  or  six  hours. 

Carbonate  of  ammonium  in  emulsion  (gr.  .3  to  5  every  two  or  three  hours) 
or  turpentine  is  often  useful. 

Bed-sores  are  to  be  avoided  by  carefull}'  keeping  the  surface  clean  and  dry, 
by  preventing  too  continuous  pressure  on  prominent  parts,  and  by  bathing 
the  skin  at  these  parts  with  some  such  astringent  wash  as  alum  in  alcohol. 
If  the  case  is  protracted  and  severe,  a  water-bed  will  be  of  great  service  in 
aiding  to  prevent  bed-sores,  as  well  as  in  their  treatment  if  unfortunately  this 
complication  has  developed.  The  best  local  applications  are  intended  either  to 
protect  the  ulcerated  surface,  as  soap  plaster,  or  to  exert  an  antiseptic  and 
healing  action,  as  in  the  case  of  ointment  of  iodoform  or  boracic  acid,  or 
powder  of  iodoform  and  bismuth,  or  the  following,  recommended  by  Dr. 
Beverly  Robinson  : 

^.  Ichthyol,  3j; 

Flexible  collodion,  f  5j. — M. 

Sig.  Use  locally. 


TREATMENT.  133 

Thrombosis  of  the  femoral  reins  should  be  treated  by  the  daily  application 
of  tincture  of  iodine  along  the  line  of  the  vessel,  by  enveloping  the  leg  in 
raw  cotton  from  the  ankle  to  the  groin,  holding  this  in  position  by  a  light 
bandage,  and  by  rest  and  elevation  of  the  member.  In  the  early  stage  of 
the  case  great  care  should  be  used  in  manipulating  the  part,  lest  a  fragment 
of  the  clot  be  detached.  Later  inunctions  may  be  used  of  dilute  mercurial 
ointment  or  of  the  following  : 

I^.   Ichthyol, 

Lanolini,  aa.  ^ij  ; 

Uug.  iodini  corap.,  3ss  ; 

Petrolati,  q.  s.  ad  siss. — M. 

When  all  tenderness  has  disappeared  and  the  swelling  has  subsided,  so  that 
it  is  safe  to  let  the  patient  leave  bed,  a  long  stocking  of  elastic  webbing 
should  be  worn,  and  in  many  cases  the  use  of  this  must  be  continued  for  a 
number  of  months. 

It  is  well  to  allude  again  to  the  importance  of  examining  the  regit)U  of  the 
bladder  morning  and  evening  during  the  continuance  of  the  ty})hoid  state  to 
guard  against  retention  of  urine. 

Treatment  of  Convalescence. — The  management  of  the  case  during  conva- 
lescence has  already  been  partially  discussed.  Although  the  appetite  returns 
and  the  patient  clamors  for  food,  the  greatest  care  must  be  observed  in  this 
respect.  No  solid  food  should  be  allowed  for  at  least  ten  days  after  all  fever 
disappears,  as  a  slight  indiscretion  in  diet  may  readily  cause  the  return  of  the 
fever.     It  is  not  necessary,  however,  to  persist  in  a  strictly  milk  diet. 

Continued  rest  is  of  equal  importance,  as  the  danger  of  perforation  is  by  no 
means  past.  It  should  be  maintained  for  at  least  a  week  after  all  fever  has 
ceased.  It  is  to  be  borne  in  mind,  however,  that  in  some  cases  a  slight  even- 
ing rise  of  temperature  persistently  continues  without  ajjparent  cause,  and 
that  this  may  sometimes  be  brought  to  a  stop  by  alU»wing  the  patient  to 
leave  the  bed. 

Caution  must  be  exercised  in  permitting  even  slight  excitement  during  con- 
valescence. Visits  of  friends  are  very  apt  to  be  followed  by  rise  of  tempera- 
ture. Tonics,  such  as  iron,  quinine,  strychnine,  and  cod-liver  oil,  are  useful 
at  this  period.  Stimulants,  too,  may  often  be  given  advantageously.  It  is 
well,  however,  to  exercise  caution  in  their  use,  lest  an  iutcmpera(e  habit 
be  acquired.     A  change  of  air  is  also  to  be  highly  recommendetl. 


TYPHUS  FEVER. 

By  WILLIAM  PEPPER. 


Definition. — Typhus  fever  is  an  acute  infectious  and  highly  contagious 
fever,  endemic  and  epidemic,  presumably  due  to  a  micro-organism  as  yet  un- 
detected, attended  with  no  characteristic  lesions  of  the  solids,  but  with  grave 
alterations  of  the  blood,  and  marked  clinically  by  an  abrupt  onset,  a  macu- 
lated and  petechial  eruption,  and  continued  high  fever  for  twelve  or  fourteen 
days,  terminating  usually  by  crisis. 

Synonyms. — Exanthematic  typhus  is  the  name  applied  to  this  disease  by 
the  Germans,  in  contradistinction  to  abdominal  typhus,  by  which  is  meant 
typhoid  fever.  This  is  also  used  at  times  by  the  French.  Petechial  typhus ; 
Spotted  or  Putrid  fever;  Hospital,  Jail,  Camp,  or  Ship  fever,  are  among  the 
best  known  and  most  apj)ropriate  of  the  older  names.  They  indicate  marked 
clinical  features  of  the  disease  or  else  the  conditions  under  which  it  has  often 
developed. 

History  and  Etiology. — While  the  ignorance  or  neglect  of  sanitation 
made  every  war  more  fatal  by  its  diseases  than  by  its  battles,  while  vessels 
were  often  floating  pest-houses,  and  jails  enclosed  as  much  physical  as  moral 
filth,  outbreaks  of  typhus  were  common.  From  the  earliest  accurate  account 
of  the  disease,  given  in  1546  by  Fracastorius,  when  he  described  the  Verona 
epidemics  of  1506  and  1508,  there  are  numerous  reports  of  violent  and  wide- 
spread outbreaks  in  all  parts  of  Europe.  It  is  indeed  difficult  to  believe  that 
prior  to  the  above  dates  the  same  thing  did  not  occur.  During  the  past  fifty 
years,  although  typhus  has  frequently  appeared,  it  seems  possible  to  note  the 
effect  of  sanitary  regulations  in  tending  to  restrict  the  spread  of  the  epidemics. 

That  the  poison  is  constantly  present  in  its  favorite  habitat  is  shown  by  the 
occasional  occurrence  of  sporadic  cases  in  crowded  cities.  It  cannot,  however, 
be  said  that  the  disease  is  endemic  except  in  comparatively  few  places,  such  as 
certain  parts  of  Great  Britain,  especially  London,  Dublin,  and  Glasgow;  in 
Brittany  in  France ;  in  the  provinces  of  the  Danube  and  the  Baltic,  etc.  In 
America  it  has  appeared  for  the  most  part  in  the  form  of  limited  outbreaks  in 
seaboard  towns,  following  the  importation  of  the  virus  from  abroad  by  fomites 
or  by  actual  cases  of  the  disease.  Independent  outbreaks  of  the  disease 
have,  however,  occurred  in  a  few  instances.  An  epidemic  occurred  in  New 
England  in  1807,  and  one  in  Philadelphia  in  1812,  after  which  the  elder 
Wood  states  that  occasional  cases  developed  in  the  slums  of  that  city  until 
1820-21.     Gerhard  gave  an  admirable  account  of  the  epidemic  he  studied  in 


1.34 


CAi\^ES.  135 

the  same  city  in  1836,  and  subsequent  outbreaks  have  been  described  by  Flint, 
DaCosta,  Loomis,  and  others.  Although  doubt  has  been  cast  on  the  diagnosis 
in  many  of  the  1723  cases  reported  to  the  Surgeon-General's  Office  during  the 
Civil  War,  1861-65,  typhus  apparently  occurred  at  various  points,  and  chiefly, 
I  believe,  among  returned  prisoners  of  war.  Tn  the  winter  of  1864-65  I  had 
the  opportunity  of  studying  a  circumscril)cd  but  severe  epidemic,  coincident 
with  an  epidemic  of  variola,  in  a  crowded  and  unhealthy  portion  of  Philadel- 
phia, where  I  then  served  as  district  dispensary  physician.  As  far  as  I  could 
determine,  both  diseases  had  been  introduced  by  retin-ncd  soldiers  and  deserters. 
In  1866  I  again  saw  much  of  the  disease  in  the  medical  wards  of  the  Pennsyl- 
vania Hospital,  while  resident  physician  in  that  institution  ;  and  during  seven- 
teen years  of  service  as  visiting  physician  to  the  Philadcli)hia  Hospital,  from 
1867  to  1884,  there  w-ere  several  outbreaks  of  tyj)hus,  during  which  a  consider- 
able number  of  cases  were  admitted  there.  In  1880  a  fatal  outbreak  occurred 
at  the  tow^n  of  Blackwood,  New  Jersey.  I  had  the  opportunity  of  studying 
it,  and  it  has  been  well  reported  by  Dr.  Branin.  The  disease  was  introduced 
to  the  almshouse  there  by  a  sailor  who  came  from  a  lodging-house  in  Phila- 
delphia where  there  were  several  cases  of  imported  tyi)hus.  The  sailor 
developed  the  disease  after  his  arrival  at  the  almshouse.  It  spread  at  once 
among  the  inmates.  At  first  the  cases  were  of  mild  tyi)e  and  distinguished 
with  difficulty  from  typhoid.  Severe  weather  came  on,  the  sanitary  condition 
of  the  almshouse  became  very  bad,  and  the  disease  assumed  a  grave  type.  In 
the  earlv  part  of  the  outbreak  all  the  cases  recovered  ;  later  the  mortality  was 
almost  50  per  cent. ;  in  all  there  were  103  cases,  with  33  deaths. 

The  causes  w^hich  predispose  to  typhus  fever  are  famine,  destitution,  over- 
crowding, and  filth.  Whatever  tends  to  reduce  vitality  and  lessen  resisting 
power,  such  as  intemperance,  overwork,  depressing  passions,  renders  the  sys- 
tem more  sensitive  to  the  virus.  Attacks  occur,  therefore,  chiefly  among  the 
lower  classes  and  in  the  overcrowded  and  dirty  sections  of  large  cities. 

Age  exerts  no  special  influence,  and  the  disease  may  occur  in  infants  and 
in  old  persons.  Naturally,  the  larger  proportion  of  cases  in  all  epidemics 
will  be  found  among  young  adults  and  the  middle-aged,  as  more  subjects 
are  exposed  to  the  causes  of  the  disease  at  these  periods  of  life.  Sex  is 
equally  without  definite  influence,  and  so  is  occupation,  unless,  as  in  the 
case  of  phvsicians,  nurses,  and  clergymen,  it  may  bring  them  in  contact 
with  patients  suffering  with  this  contagious  malady.  Laundresses  who  are 
called  on  to  wash  the  linen  of  typhus-fever  patients  are  also  peculiarly  lia- 
ble to  be  affected.  Epidemics  may  occur  at  ail  seasons  and  in  nio>t  vane.l 
localities,  but  they  are  most  frequent,  as  alrea.ly  stated,  in  s(>aboard  t..wns  and 
during  the  winter,  when  the  ventilation  and  eleanbness  of   hous.s  an^  apt  to 

be  most  defective. 

The  exeiting  came  of  tvphus  is  exclusively  the  sp.rific  virus.  I  !.<•  extreme 
contagiousness  of  this  disease  is  so  fully  establishcl  that  the  ..vi.len.v  nee.i  no, 
be  recited.  Murchison  formulates  the  con.-lusions  as  fbllows  :  W  hen  Ivplius 
appears  in   a   house  or  a   loeality  il    usually  sp.vads  will,   grrat    rapidity;   the 


136  TYPHUS  FEVER. 

imuiber  of  cases  in  llie  house  or  in  the  circumscribed  locality  is  in  direct  pro- 
portion to  the  relation  between  the  well  and  the  sick ;  individuals  living  in 
localities  where  the  disease  is  unknown  acquire  it  on  visiting  typhus  patients 
in  a  distant  hx-ality  ;  the  disease  is  often  imported  by  infected  persons  into 
previously  healthy*  localities ;  and,  finally,  the  contagiousness  of  typhus  is 
established  by  the  success  of  prophylactic  measures,  and  especially  by  the  iso- 
lation or  removal  of  the  earliest  cases. 

The  virus  may  acquire  intense  energy.  It  is  not  necessary  that  there 
should  be  actual  contact  with  the  sick,  and  yet  the  distance  through  which  the 
])oison  can  exert  its  influence  is  limited.  Brief  visits  to  a  single  case  may  be 
made  with  impunity,  but  if  several  cases  are  confined  in  one  room  the  air  be- 
comes so  infected  that  those  who  enter  are  apt  to  contract  the  disease  though 
they  may  not  go  within  several  feet  of  the  sick.  A  large  proportion  of  per- 
sons unprotected  by  a  previous  attack  contract  the  disease  when  first  exposed 
to  it.  As  would  be  expected,  therefore,  many  physicians  and  nurses  lose 
their  lives  during  large  epidemics.  There  is,  however,  great  difference  in  the 
susceptibility  of  different  individuals  and  of  the  same  individual  at  different 
times.  Thus,  one  of  my  nurses,  who  had  passed  unscathed  tlirough  previous 
epidemics  of  typhus,  and  in  the  severe  outbreak  here  in  the  winter  of  1864-65 
had  been  most  faithful  and  devoted  in  his  care  of  many  cases  in  the  fever 
ward,  escaped  until  May  1,  when  he  suddenly  developed  a  malignant  attack, 
and  died  in  four  days.  The  disease  is  contagious  throughout  its  entire  course, 
and  it  is  difficult  to  say  if  it  be  more  so  at  one  period  than  another. 

Although  it  is  evidently  difficult  in  such  cases  to  exclude  other  sources  of 
infection,  it  seems  that  typhus  may  be  contracted  from  the  corpses  of  those  who 
have  died  of  that  disease.  I  shall  never  forget  the  sudden  impression  made 
upon  me  as  I  dissected  the  body  of  a  subject  dead  of  malignant  typhus  in  1866. 
It  seemed  as  though  a  thick,  strong  vapor  rose  from  the  open  surfaces  and 
struck  me  in  the  face.  Within  ten  minutes  I  was  too  giddy  and  weak  to 
walk  ;  a  chill  occurred  within  an  hour,  a  high  fever  followed  immediately,  and 
an  attack  of  moderate  severity  ensued.  I  had,  however,  been  in  almost  daily 
contact  with  typhus  patients  for  a  year  previously. 

Tlie  avenue  by  which  the  infection  gains  access  to  the  system  is  not  def- 
initely known.  There  is  no  evidence  to  show  that  it  is  by  contamination  of 
drinking-water  or  other  ingesta.  Analogy  is  opposed  to  the  view  that  it  is 
through  the  skin.  It  seems  probable  that  it  is  by  way  of  the  inspired  air 
that  the  disease  is  contracted.  The  poison  attaches  itself  tenaciously  to  cloth- 
ing and  bedding,  and  the  fever  may  be  thus  communicated  by  fomites  at  con- 
siderable intervals  of  time  and  space.  An  attack  of  typhus  protects  strongly 
and  usually  permanently  against  subsequent  attack.  Both  relapses  and  recur- 
rences are  extremely  rare. 

No  typhus  microbe  has  as  yet  been  discovered.  Hlava  in  1888,  at  Prague, 
fijund  a  streptococcus  which  he  was  dis})osed  to  believe  peculiar  to  the  dis- 
ease. But  he  found  it  only  in  20  out  of  33  cases,  and  Cornil,  Thoinot,  and 
others  are  not  disposed  to  regard  it  as  specific.     Thoinot  gives  fresh  experi- 


MORBID    AXATOMY.  137 

meuts  to  confirm  tlie  view  that  theblood  of  typhus  patients  will  not  convey 
the  disease  to  animals  by  inoculation. 

The  effect  of  overcrowding,  defective  ventilation,  and  filth  in  increasing 
the  virulence  of  the  poison  is  so  decided  that  the  question  has  naturally  arisen 
if  under  such  influences  it  may  not  arise  dc  novo.  This  view  has  been 
espoused  by  some  high  authorities,  but  if  the  ])oison  is,  as  is  probable,  asso- 
ciated with  a  microbe,  all  analogy  is  opposed  to  its  spontaneous  generation.  A 
moi-e  plausible  suggestion  seems  to  be  that  the  microbe,  which  may  be  widelv 
distributed,  and  under  ordinary  circumstances  possessed  of  but  moderate  path- 
ogenic properties,  acquires,  when  cultivated  in  contact  with  the  foul  effluvia  of 
human  beings  overcrowded,  filthy,  and  degraded  in  vitality,  such  virulent 
])roi)erties  as  make   it  the  effective  cause  of  tyi)hus  fever. 

Morbid  Anatomy. — There  are  no  lesions  of  the  solids  peculiar  to  ty|)hus 
fever.  As  a  rule,  rigor  mortis  is  not  marked.  Putrefaction  occurs  rai)idly 
after  death.  The  petechial  eru])tiou  persists  after  death,  and  large  purple 
patches  are  present  on  the  dependent  portions  of  the  body. 

The  blood  is  profoundly  altered.  It  is  dark  and  fluid  ;  the  lining  of  the 
aorta  is  deeply  stained  by  imbibition;  such  clots  as  are  present  are  soft  and 
dark  like  currant  jelly.  Eccliymoses  may  be  seen  on  all  the  serous  membranes, 
and  especially  on  the  pericardium.  The  muscles  are  dark  and,  notably  in  the 
case  of  the  heart,  have  undergone  granular  degeneration.  Plxtravasations  of 
blood  are  occasionally  noted  in  the  substance  of  the  n)uscles,  more  fre(|uently 
in  the  recti  than  elsewhere.  The  liver  is  softened  and  somewhat  swollen. 
The  spleen  is  enlarged,  though  usually  not  so  much  so  as  in  typhoid  :  its  pulp 
is  greatly  softened,  even  to  diffluence  in  many  cases.  In  some  of  the  cases 
I  observed  it  was  from  three  to  five  times  its  normal  size  and  extremely  soft. 
The  kidneys  are  swollen  and  enlarged,  and  may  show  the  changes  of  infectious 
nephritis.  Congestion  and  catarrh  of  the  larynx  and  bronchial  tubes  are  com- 
mon. Hvpostatic  congestion  of  the  lungs  is  very  frequently,  and  pneumonia 
not  rarely,  met  with  :  the  latter  may  be  either  croupous  or  catarrhal.  Pleu- 
risy, either  sero-plastic  or  purulent,  is  an  occasional  (•()m])lication.  On  the 
whole,  the  lesions  of  the  respiratory  organs  arc  nuicli  less  constant  and 
pronounced  than   in  typhoid   fever. 

The  gastro-intestinal  tract  presents  no  characteristic  lesions.  Congestion 
and  occasionally  ccchymoses  of  the  nmcous  menibrane  of  the  stomach  may  be 
noted.  Peyer's  patches  may  be  slightly  swollen  and  present  the  shaven-beard 
appearance,  but  not  in  a  degree  greater  than  is  occasionally  Ibuiid  in  all  violent 
infections.  The  solitary  glands  also  are  sometimes  unduly  i)r()minent.  The 
Breslau  epidemic,  in  which  Lebert  reports  the  occiinvncc  of  small  ulcers  of 
the  solitary  and  agminated  glands,  was  certainly  e.\ee|)tional.  In  iIh'  I'hda- 
delphia  epidemic  of  1864-05,  where  diarrluea  oeeiinvd  in  Inlly  (.iie-(liinl  the 
cases,  some  enlargement  of  Peyer's  patches  and  .if  tlie  solitary  glands  was  found 
repeatedly,  i)ut  no  ulceration  was  rejHtrted.  A  teiideiicy  to  g.neial  l.v|.erplasia 
of  the  lymphoid  tissue  is  present,  but  in  a  inueli  jess  marked  degree  t inn  in 
relapsing  or  tvphoid  fever.      The  eerebra!  meninges  are  n-^nally  .■ongr-sfe.j   and 


138  TYPHUS  FEVER. 

the  sinuses  filled  with  dark  blood.  A  moderate  amount  of  subarachnoid  and 
ventricular  effusion  of  serum  may  exist,  but  not  to  a  greater  degree  than  in 
acute  diseases  unattended  with  the  intense  nervous  disturbances  of  typhus. 
Oro-anic  lesions  of  the  nervous  centres  are  conspicuously  absent  as  a  rule. 

General  Clinical  Description. — The  incubation  of  typhus  fever  varies 
from  a  few  hours  to  two  weeks  or  even  longer,  according  to  the  virulence  of 
the  infection  and  the  susceptibility  of  the  individual.  Twelve  days  may  be 
retT-arded  as  a  safe  average.  Prodromes  are  more  often  absent  than  present. 
There  may  be  a  feeling  of  general  indisposition,  with  weakness,  vertigo,  and 
loss  of  appetite,  for  two  or  three  days.  The  invasion  of  the  disease  is  as  a 
rule  abrupt,  with  sudden  vertigo,  rigor  or  actual  chill,  extreme  weakness,  and 
rapid  rise  of  temperature.  The  patient  is  forced  to  take  to  bed  at  once  in 
most  cases.  Headache,  pains  in  the  back  and  limbs,  and  soreness  of  the  flesh 
appear  speedily.  Nausea  and  vomiting  are  not  rare.  The  tongue  is  moist  at 
first,  with  but  slight  coating.  The  abdomen  is  not  distended,  and  constipation 
is  usual.  Epistaxis  is  rare.  The  expression  is  heavy  and  like  that  of  one  in- 
toxicated. Tlie  face  is  flushed  uniformly,  and  the  eyes  are  congested.  Delir- 
ium may  occur  almost  at  once,  and  serious  nervous  symptoms  speedily  ensue. 
Prostration  may  appear  early,  and  is  so  marked  as  to  be  highly  characteristic. 

The  fever  rises  so  rapidly  that  a  temperature  of  104°  or  105°  may  occur 
on  the  second  or  third  day,  and  this  may  be  the  highest  point  attained  during 
the  attack.  The  daily  variations  are  not  marked.  The  sense  of  heat  imparted 
to  the  hand  even  exceeds  the  degree  actually  present.     (See  Fig.  10.) 

The  pulse  is  rapid  from  the  first.  Not  rarely  it  reaches  110  or  120  by  the 
third  day,  and  this  rapidity  increases  as  the  disease  advances.  Even  if  full  and 
strong  for  a  day  or  two,  the  pulse  speedily  grows  small,  soft,  and  compressible, 
and  the  heart's  action  is  found  to  fail  rapidly  in  force.  The  respirations  are 
hurried,  in  accordance  with  the  height  of  fever  and  the  acceleration  of  the 
pulse.  If  any  pulmonary  complication  develops,  the  disturbance  of  pulse 
and  breathing  may  become  extreme. 

On  the  third  or  fourth  day  the  typhus  eruption  makes  its  appearance  in  the 
form  of  numerous  irregularly-rounded  spots,  of  a  dull-red  color,  barely  ele- 
vated above  the  skin.  These  disappear  on  pressure  at  first,  but  soon  it  is 
found  that  the  centre  persists  on  pressure,  and  later  the  entire  spot  is  con- 
verted into  a  petechia.  It  is  preceded  or  accompanied  by  an  irregular  conges- 
tion of  the  derm  which  causes  a  subcuticular  mottling. 

By  the  end  of  the  first  week  the  disease  has  reached  its  height.  The  stupor 
from  which  the  disease  takes  its  name  is  pronounced.  The  decubitus  is  dorsal, 
and  the  patient  must  from  time  to  time  be  turned  on  either  side.  There  is  a 
deep  dusky  flush  of  the  face,  and  the  expression  is  profoundly  dull.  It  is 
often  impossible  to  rouse  the  patient  to  answer.  Deliriimi  may  be  low  and 
muttering  or  wild,  excited,  and  noisy.  Despite  the  stupor,  sleep  may  be 
almost  absent.  The  prostration  and  muscular  weakness  are  extreme.  Tremor, 
difficulty  in  protruding  the  tongue,  retention  of  urine,  slipping  down  in  the 
bed,  and  inability  to  turn  are  often  present.    The  severe  headache  of  the  earlier 


SPECIA  L    S  } WP TOMS. 


l.">9 


days  has  subsided,  or,  if  it  continues,  may  be  associated  with  innscuhu'  rigidity 
and  retraction  of  the  head.     Tlie  fever  continues  uniforndv  hiuh,  with  a  drv 

Fig.  10. 


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Temperature-chart  of  I'alicnt,  at.  I'.i,  siilleriii!,'  tr<iiii  'ly|ilnis  I'tvir 

burning  skin.  The  pulse  is  small,  weak,  and  rapid  ;  the  impul.>^e  and  first 
•sound  of  the  heart  are  almost  effaced.  The  tongue  is  dry  and  brown,  tremu- 
lous, and  protruded  with  great  difficulty  if  at  all.  Liquid  may  .still  be  taken 
freely,  and  digestive  disturbances  are  for  the  mo.^^t  pait  wanting.  Some 
enlargement  of  the  liver  and  spleen  is  present.  The  urine  is  scanty,  con- 
centrated, highly  colored,  and  often  albuminous.  No  second  croj)  of  erup- 
tion has  appeared  ;  the  spots  have  become  to  a  large  extent  petechial,  and  after 
the  ninth  or  tenth  day  begin  to  change  color  and  fade.  The  alarming  or  even 
desperate  condition  of  the  patient  grows  aggravated  as  the  limit  of  the  dis- 
ease approaches.  A  sudden  critical  improvement  occurring  about  the  end  of 
the  .second  week,  with  a  rapid  fall  in  fever  and  abatement  of  all  symptoms, 
ushers  in  a  .speedy  and  uninterrupted  convalescence.  Or,  on  the  other  hand, 
complication.s  arise  and  may  determine  a  fatal  issue  to  the  ca.se,  or  the  symj)- 
toms  of  infection  and  of  cerebral  or  cardiac  failure  progress,  and  death  occurs 
from  the  middle  to  the  end  of  the  .second  week. 

Special  Symptoms.— The  appearance  of  th<"  patient  is  highly  charactcr- 
i.stic.  It  is  true  that  in  some  cases  of  typhoid  fever  and  in  s<mie  of  . •erel.ro- 
spinal  fever  a  similar  fades  appears,  but  mneh  more  (ron.stanlly  in  typhus  is 
there  a  uniform  deep  du.sky  flush  of  the  face,  with  a  gla/.ed  a|.|..iirMn.v  of  the 


140  TYPHUS  FEVER. 

skiu,  a  fiuely-injected  eye  with  contracted  pui)il,  and  an  expression  occasion- 
ally wild  and  fierce,  but  usually  veiled,  heavy,  and  profoundly  dull. 

The  nervous  symptoms  of  typhus  fever  are  most  severe  and  characteristic. 
Muscular  debility  is  extreme  from  the  very  first,  so  that  it  is  uncommon  to 
have  patients  walk  about  for  more  than  a  few  hours  after  the  invasion, 
althongh  cases  are  occasionally  met  with  of  such  mild  type  as  to  ])resent 
themselves  at  the  out-door  department  of  a  hospital  with  the  rash  already 
out.  It  is  commonly  associated  with  great  vertigo,  which  makes  the  j^atient 
still  more  helpless,  and  throughont  the  case  this  latter  symptom  may  be  dis- 
tressing, causing  a  frequent  feeling  that  the  bed  is  sinking  or  swimming  away. 
The  prostration  increases  as  the  disease  advances.  It  shows  itself  in  the  tend- 
ency to  heart  failure,  in  the  retention  of  urine,  in  difficulty  in  protruding  the 
tonwue  or  in  swallowing,  in  inability  to  turn  in  bed,  in  a  high  degree  of  tremor 
and  subsultus. 

Pain  is  often  severe  in  the  early  stage.  Headache  is  its  most  constant 
form  :  it  may  be  intense,  and  in  cases  of  the  cerebro-spinal  type  is  asso- 
ciated with  rigidity  of  the  muscles  of  the  neck  and  retraction  of  the  head. 
Cutaneous  hvpersesthesia  and  muscular  soreness  may  also  be  marked. 

It  is  only  in  very  exceptional  cases  that  delirium  is  absent,  though  it  varies 
much  in  its  degree.  As  a  rule,  it  ai)pears  early  and  continues  throughout  the 
case.  It  may  be  mild  and  muttering  or  noisy  and  wild.  Hallucinations  may 
occur,  and  patients  have  given  me  apparently  coherent  accounts  of  the  most 
improbable  occurrences.  In  one  instance  a  woman  of  excellent  character 
accused  herself  of  lewd  thoughts  and  conduct  in  her  past  life,  and  repeated 
these  accusations  daily  through  a  considerable  ])art  of  the  attack,  though  it 
was  apparent  on  her  recovery  that  no  recollection  of  such  remarks  was  retained. 
It  required  decisive  explanations  to  avoid  unpleasant  social  results,  so  emphatic 
and  ]ilausible  had  been  her  accounts.  Stupor  is  equally  common,  and  varies 
from  hebetude  to  profound  coma.  Only  in  very  mild  cases  is  there  absence 
of  the  peculiar  mental  confusion  and  heaviness  with  besotted  expression  of 
countenance  from  which  the  disease  gets  its  name.  Oscillation  of  the  eyeballs 
is  an  unfavorable  symptom  occasionally  metwith.  Convulsions  may  occur  at 
the  onset  in  children  without  necessarily  grave  significance:  occurring  in  adults 
toward  the  close  of  the  second  week,  they  are  evidences  of  intense  toxaemia, 
often  with  renal  complication,  and  are  ominous.  In  spite  of  the  stupor,  true 
refreshing  sleep  is  apt  to  be  wanting,  and  insomnia  may  persist  to  a  dangerous 
extent.  Careful  attention  to  this  point  is  always  demanded,  as  fatal  exhaustion 
may  be  induced  by  prolonged  watchfulness. 

The  fever  runs  a  course  of  about  two  weeks.  It  is  ushered  in  by  a  rigor 
which  may  be  slight  or  may  amount  to  a  hard  chill.  The  latter  is  far  more 
frefjuent  than  in  typhoid.  The  initial  rise  of  temperature  is  sudden  and  high, 
and  103°  is  often,  and  104°  occasionally,  reached  by  the  evening  of  the  first 
day.  Wunderlich  reports  104.9°  in  one  case  at  that  period,  and  Lebert  106.4° 
on  the  second  evening.  The  maximum  of  the  case  is  reached  from  the  third  to 
the  fifth  dav.     It  varies  from  103°  in  mild  cases  to  105°  in  severe  cases,  and 


^SPECIAL    SYMPTOMS.  141 

even  to  106°  in  the  grave  form.  In  one  case  at  Blackwood,  N.  J.,  it  was 
109°  on  the  fourth  day,  and  yet  tlie  patient  ultimately  recovered.  The 
remissions,  which  usually  occur  in  the  mornings,  are  apt  to  be  hut  slight; 
the  high  fever  persists  with  great  um'tormity.  During  the  second  week  the 
fever  rarely  exceeds  the  maxinuun  of  the  first  week  unless  inflammatory  com- 
plications occur,  or  in  fatal  cases,  where  death  is  often  preceded  hy  a  sudden 
rise  to  106°,  or  even  to  109°.  About  the  twelfth  day  in  favorable  cases  a  crisis 
occurs,  marked  by  an  abrupt  fall  in  temperature,  and  often  by  some  critical  dis- 
charge. Thoinot  states  that  there  is  never  a  sudden  fall  in  the  temju'raturc,  but 
this  is  totally  opposed  to  general  experience.  I  have  seen  it  drop  five  degrees 
in  twenty-four  hom-s,  and  even  more  abrupt  and  extensive  falls  are  recorded. 
The  teniperature  often  becomes  sid)uormal  and  remains  so  for  several  davs. 

The  symptoms  furnished  by  the  digestive  system  in  typhus  arc  usuallv 
unimportant.  The  tongue  may  remain  moist  and  but  slightly  coated  in  mild 
cases,  but  more  commonly  it  becomes  dry  and  brown  or  even  i)]ackish  and 
cracked.  It  is  tremulous,  and  in  bad  cases  it  is  difficult  or  impossible  to  pro- 
trude it.     Sordes  form  abundantly  on  the  teeth  and  lij)s. 

The  appetite  is  variable.  Usually  there  is  anorexia,  but  thirst  is  preserved. 
Occasionally  relish  for  food  is  not  entirely  lost  at  any  time  during  the  case. 
When  stupor  is  marked  no  request  for  nourishment  or  water  may  be  made, 
though  they  wmII  be  swallowed  willingly  when  otfcred.  Nausea  may  exist  with 
the  intense  vertigo  at  the  onset,  but  both  it  and  vomiting  are  rare  symjitoms 
during  the  disease.  Urfemia  or  cerebral  irritation  may  induce  vomiting  toward 
the  close  of  the  case.  The  abdomen  is  not  distended,  though,  on  the  other 
hand,  retraction  is  I'are.  The  condition  of  the  bowels  varies  in  different  epi- 
demics. Constipation  is  the  rule,  and  I  have  often  known  it  difficult  to 
secure  satisfactory  movements  with  simple  enemas.  A  tyj>ical  typhoid  state 
develops  in  some  cases,  with  mcteorism  and  looseness  of  the  bowels,  but 
even  then  neither  ochre-colored  stools  nor  intestinal  luemorrhages  occur.  In 
some  epidemics,  as  at  Philadelphia  in  1S64-65,  tiiarrhiea  maybe  present  in 
fully  one-third  the  cases. 

The  liver  is  occasionally  soniewhat  swollen,  the  sj)lccn  much  more  fVc- 
(picntly  so,  but  to  a  less  degree  and  with  less  constancy  than  in  typhoid  fever. 
Tenderness  on  pressure  is  apt  to  cxi^l  over  the  liver  or  spleen  if  enlarged. 

A  rapid  pulse  is  nearly  always  ])rcscut.  Its  rate  corrcspiMids  with  the 
height  of  fever  and  with  the  degree  of  disturbance  of  the  cardiac  ganglia  and 
muscle.  In  mild  cases  with  moderate  fever  it  may  at  no  time  exceed  96  or 
100.  Occasionally  a  disproportionate  slowness  may  be  noted,  and  if  this  be 
unaccompanied  by  alarming  uraemie  or  cerebral  symptoms,  it  is  lavoiablc,  as 
indicating  a  large  reserve  of  cardiac  power.  \\n\  nsnally  th.'  pnlsc-rate  rises 
rapidly  from  the  onset  and  varies  between  n<»  nnd  120  in  eases  of  ordinary 
severity.  In  children,  in  sensitive  females,  and  in  grave  cases  a  pulse  of  i;{(> 
to  160  is  iKjt  uncommon.  SufMen  slowing  of  the  pidse  withont  fall  in  tempera- 
ture or  improvement  in  nervous  symptoms  is  of  serions  siguificanc.'.  Wlieu 
the  ci-itical  fall  of  tcnii.cnilin-e  (.ccui'<,  aliont  the  clox'  of  the  .second  wceU,  the 


142  TYPHUS   FEVER. 

pulse-rate  should  fall  (leeidedly,  though  not  so  rapidly.  Abnormal  slowness 
to  60,  or  even  to  48,  is  not  rare  during  convalescenee.  In  one  case  in  the 
Blackwood  epidemic  the  pulse  on  the  twentieth  day  was  24,  with  respirations 
16  and  temjiorature  98°  ;  recovery  followed,  and  by  the  thirty-second  day  the 
pulse  had  attained  its  normal  rate.  Excitement  or  exertion  will  rapidly  send 
the  pulse-rate  up  again,  however,  and  this  undue  mobility  of  the  heart  may 
last  for  wrecks.  When  the  muscular  substance  or  nervous  ganglia  of  the 
heart  are  seriously  involved  the  pulse  may  be  so  rapid,  small,  and  irregular 
as  to  be  uncoimtable;  the  pulse  taken  at  the  wrist  may  diifer  widely  from 
the  count  of  the  cardiac  impulses  at  the  prsecordia,  and,  if  life  be  spared,  pro- 
nounced weakness  and  irritability  of  the  heart  may  persist  long  after  recov- 
ery is  otherwise  complete. 

The  character  of  the  heart's  action  and  pulse  is  even  more  important  than 
the  rate.  In  mild  cases  and  in  the  young  and  strong  the  pulse  may  retain 
fulness  and  force  ;  but  there  is  pronounced  tendency  to  failure  of  cardiac 
]iower,  and  as  a  rule  the  pulse  grows  soft,  small,  and  compressible  in  two  or 
three  days,  and  from  that  onward  its  weakness  increases.  For  some  time 
before  the  crisis,  in  very  grave  cases  which  nevertheless  recovered,  I  have 
been  unable  to  detect  the  pulse  at  the  wrist.  Dicrotism  is  less  common 
than  in  typhoid. 

The  cardiac  impulse  soon  grows  weak  and  diffuse ;  it  becomes  impossible 
to  count  the  apex-beats  by  palpation  ;  the  first  sound  is  altered  in  character, 
becoming  short,  clear,  and  valvular,  and  ultimately  almost  inaudible,  owing  to 
increasing  impairment  of  the  ventricular  contractions.  A  blurred  or  murmur- 
ish  character  of  the  first  sound  is  also  often  present,  but  actual  endocarditis  is 
rare.  These  changes  indicate,  and  to  some  extent  measure,  the  dyscrasia  of 
the  blood,  the  degeneration  of  the  cardiac  muscle,  and  the  failure  of 
innervation. 

The  pulse-respiration  ratio  is  fairly  preserved,  so  that  the  breathing  is 
usually  30  to  40  in  the  minute.  I  have,  however,  observed  the  respiration  at 
50  and  at  40,  with  a  pulse  of  104  and  of  88,  respectively,  and  without  demon- 
strable pulmonary  lesion  in  either  case.  Respiration  becomes  much  more  rapid 
in  case  of  pulmonary  complications,  not  rarely  reaching  50,  or  even  60.  As 
the  development  of  such  complications  is  often  insidious,  cautious  explorations 
of  the  chest  should  be  made  daily.  Weak  respiratory  murmur,  with  fine  ex- 
pansion crepitus  on  deep  breathing  heard  over  the  lower  lobe  behind,  may 
often  be  found  as  evidence  merely  of  hypostatic  congestion  and  imperfect 
expansion.  But  even  when  pneumonia  exists  the  percussion-dulness  may  be 
only  relative  and  bronchial  respiration  be  imperfectly  developed.  Cough  may 
lack  force,  and  the  muco-sanguinolent  expectoration  be  scanty  and  raised  with 
difficulty.  The  increased  lividity  and  cyanosis,  elevated  temperature,  and  car- 
diac failure  confirm  the  susi)icion  aroused  by  the  physical  signs. 

Bronchitis  in  any  serious  degree  is  greatly  less  frequent  than  in  typhoid. 
Sonorous  and  sibilant  rales  scattered  over  the  chest  are  common,  and  indicate 
congestion   and  slight  catarrh.     The  character  of  respiration   varies  greatly. 


SPECIAL    .SYMPTOMS.  143 

If  there  be  much  pulmonary  congestion,  it  is  shallow  anil  superior  costal  in 
type.  If  the  cerebral  symptoms  and  the  toxaemia  are  profound,  it  is  irregu- 
lar, jerking,  or  even  stertorous.  Under  these  circumstances  its  frequency  may 
fall  below  the  normal.  An  inverted  type  of  respiration,  due  to  pneumogastric 
paresis,  is  a  fatal  symptom.  The  expired  air  is  heavy  and  offensive.  Little  is 
known  of  its  composition  save  that  it  often  contains  an  excess  of  ammonia. 

Hiccough  is  not  rare  in  grave  cases.  It  is  im])ortant  to  be  aware  that 
epistaxis  is  of  quite  frequent  occurrence  in  some  epidemics.  It  was  noteil  in 
twelve  out  of  one  series  of  thirty  cases  under  ray  observation. 

The  urine  is  scanty  and  highly  febrile.  It  is  highly  colored,  of  strong, 
offensive  odor,  and  apt  to  become  ammoniacal.  The  urea  aixl  uric  acitl 
are  increased,  while  the  chlorides  are  greatly  diminished  or  absent.  Albu- 
min is  usually  present  in  all  but  mild  cases.  The  amount  is  not  great,  nor 
does  it  it  add  materially  to  the  gravity  of  the  case  unless  infectious  nephritis  be 
present,  Avhen  albumin  is  more  abundant,  with  granular  or  epithelial  tube-casts. 
The  proportion  of  cases  in  which  nei)hritis  occurs  varies  much  in  different  e]ii- 
demics  ;  its  existence  adds  decidedly  to  the  gravity  of  the  case.  If  the 
patient  survives  the  fever,  the  nephritis  rarely  persists.  At  the  time  of  the 
crisis  copious  discharges  of  urine,  at  first  loaded  with  urates  and  then  very 
light  colored  and  of  low  specific  gravity,  sometimes  occur.  As  already  stated, 
retention  of  urine  is  of  frequent  occurrence.  The  urine  may  be  passed  if  the 
]>atient's  attention  is  drawn  to  it ;  but  the  region  of  the  bladder  must  be  exam- 
ined regularly,  and  the  catheter  be  used  if  required. 

The   cutaneous    symptoms  demand  careful   study.      The  skin   imi)arts   a 
peculiar  sense  of  pungent  heat,  aptly  styled   calor  mordax.     It  exhales  an 
odor  which,  combined  with  that  of  the  breath,  may  be  recognized  as  charac- 
teristic after  a  few  experiences.    There  is  but  little  tendency  to  moisture,  so  that 
sudamina  are  of  rare  occurrence  in  typhus  as  contrasted  with  tyi>hoid  fever.    A 
copious  sweat  may  attend  the  critical  fall  in  the  temperature.     Cold,  clammy 
sweats  of  the  head  and  extremities,  with  continued  high  central  temperature, 
often  presage  fatal  cardiac  failure.     Herpetic  eruptions  are  of  rare  occurrence. 
The  eruption  of  typhus  consists  of  a  combination  of  subcuticular  mottling 
with  the  characteristic  macules.     The  mottling  is  not  essential  or  constant, 
tiiough  of  common  occurrence.     It  may  ai)pear   as  cai-ly   as  the   fii-st   day. 
The  spots  or  macules  appear,  as  a   rule,  on  the  third   or  fourth  day  ;  ihcy 
may  be  postponed  for  several  days  later,  as  to    (he  seventh   or  even   (cnth 
day.     They  come  out  in  a  single  crop,  ai)pcaring  first   on   (he  trunk,   then 
on'  the  extremities,  and  less  constantly  or  copiously  on  the  face.     'V\w  spots 
are  irregularlv  rounded   in   form,  barely  if  at   all  el.'VMt<Ml  above  (h.-  surface, 
and    vary  in   size   from  that   of  the   point    of  a    pin    to   tw..   or   three  lines   in 
diameter.     Both   the  nundicr  and  the  coh.r  ..f  (he  spots  bear  relation  to  the 
.severity  of  the  case.     As  a  rule,  (he  more  copious    an<l  darker-eoh.red   the 
eruption  the  deeper  the  infection.      In  mild  <ases  the  sj.ots  may  be  pinki.^h  ..,• 
rose-colored  and  disaj.pear  readily  ..n   pressure,  so  as    (o  res.Muble  (hos..  ..( 
tvphoid,    and    may   continue    th.i-    until    they    fade.      rsnally    they    an^   ol    a 


144  TYPHUS   FEVER. 

deeper  and  duller  red,  more  resembling  the  eruption  of  measles,  and  though 
they  disappear  on  pressure  at  first,  there  is  in  bad  cases  a  gradual  conversion 
of  the  macules  into  petechiae.  In  some  cases  the  spots  fade  ra])idly  in  the 
course  of  three  or  four  days,  but  when  petechial  they  last  throughout  the  case, 
fading  away  gradually  toward  the  crisis  or  remaining  visible  after  death.  In 
addition  to  these  small  petechise,  tiiere  may  be  ecchymotic  patches  at  various 
points  of  the  surface  or  on  the  conjunctivae.  A  fine  branny  desquamation 
occasionally,  but  not  generally,  follows  the  subsidence  of  the  eruption.  It 
may  affect  the  entire  surface,  even  the  hands  and  the  soles  of  the  feet  des- 
quamating. 

Varieties. — For  practical  purposes  it  is  enough  to  recognize  the  mild,  the' 
ordinary,  the  grave,  and  the  malignant  varieties  of  typhus.     In  some  epidemics 
a  considerable  proportion  of  mild  cases  occur,  and  more  rarely  walking  and 
also  abortive  cases,  corresponding  to  those  respective  forms  of  typhoid,  are 
met  with. 

The  grave  form  embraces  cases  with  serious  comjilications,  such  as  pneu- 
monia or  nephritis,  and  also  those  cases  whose  gravity  is  due  to  the  undue 
prominence  of  certain  groups  of  symptoms.  Under  the  latter  heading  must 
be  classed  the  ataxic  type,  with  a  high  degree  of  irregular  nervous  disturbance, 
and  the  adynamic  type,  with  extreme  prostration  and  tendency  to  heart  failure. 
Murchison  describes  an  ataxo-adynamic  type  which  combines  the  features  of 
both.  The  cerebro-spinal  variety,  of  special  interest  owing  to  its  resemblance 
to  cerebro-spinal  fever,  is  a  form  of  the  ataxic  type. 

Malignant  typhus,  also  called  typhus  siderans,  may  prove  fatal  in  twelve  to 
twenty-four  hours.  The  virus  acts  with  concentrated  intensity  ;  immediate 
dissolution  of  the  blood  occurs  ;  petechiae  may  appear  in  large  numbers,  and 
large  ecchymotic  patches  form  on  dependent  portions  of  the  body.  Hyper- 
pyrexia is  developed  in  a  few  hours ;  the  extremities  may  be  cold  and  livid^ 
while  the  rectal  temperature  is  106°  or  107°  ;  the  pulse  becomes  running  and 
thready,  and  delirium  and  stupor  appear  early.  Death  may  ensue  so  speedily 
as  to  leave  the  diaji-nosis  in  doubt  unless  the  evidence  of  infection  is  clear. 

Complications  and  Sequelae. — Epidemics  of  typhus  vary  greatly  as  ta 
the  frequency  with  wiiich  complications  occur.  It  is  an  error  to  think  them 
rare,  and  as  they  often  develop  insidiously,  there  is  great  danger  of  overlook- 
ing serious  complications  unless  continual  watchfulness  be  exercised. 

Hypostatic  congestion  of  the  lung.s,  bronchitis,  and  pneumonia  are  of  fre- 
quent occurrence.  The  pneumonia  may  be  either  croupous  or  catarrhal,  is  apt 
to  run  an  irregular  course,  adds  greatly  to  the  danger  of  the  case,  and  occa- 
sionally terminates  in  gangrene  or  runs  into  a  chronic  form. 

Several  loose  dark  stools  occur  daily  in  a  considerable  proportion  of  cases 
in  some  epidemics,  but  severe  diarrhcea  is  rare.  Intestinal  haemorrhage  doe.s^ 
not  occur,  save  in  the  grave  haemorrhagic  type. 

A  small  amount  of  albumin  is  present  in  the  urine  of  most  cases  of  typhus 
fever,  but  does  not  necessarily  imply  the  existence  of  nephritis.  Careful  micro- 
scopical examination  will,  moreover,  .show  tube-ca.sts  and  renal  epithelium  in 


PROGXOSIS.  145 

a  considerable  proportion  of  severe  oases.  Tliey  may  be  IoiukI  even  in  urine 
which  is  amber-eoh)recl  with  but  very  slight  deposit.  I  am  not  prepared  to 
say  that  a  slight  degree  of  catarrhal  nephritis  adds  alarmingly  to  the  danger  of 
the  case;  certainly  most  of  my  own  cases  where  it  was  ])resent  recovered.  It 
is  always  a  source  of  anxiety,  however,  and  if  the  urine  be  scanty  and  the 
albumin  abundant  uriemic  symptoms  are  often  added  to  the  existing  nervous 
disturbances  and  the  danger  is  greatly  enhanced.  If  the  patient  survives  the 
fever,  chronic  nei>hritis  rarely  persists  as  a  sequel  unless  the  patient  is  allowed 
to  expose  or  exert  himself  at  too  early  a  period  of  convalescence. 

Epistaxis  is  occasionally  met  with,  even  when  no  pronoiuiced  hjemorrhagic 
tendency  exists.  Ha-matemesis  is  nnich  more  rare.  In  certain  iiffimorrhagic 
cases  blood  escapes  from  almost  all  surflices,  in  addition  to  numerous  subcuta- 
neous ecchymoses. 

Parotitis  is  both  more  frequent  and  more  dangerous  than  in  tvj)h()id. 
Both  glands  may  be  affected  simultaneously,  though  more  cominoidv  but 
one,  or  first  one  and  then  the  other.  Suppuration  usually  ensues,  and  the 
gland  breaks  down  and  is  discharged  in  small  necrosed  fragments.  1  have 
seen  death  result  from  parotitis  arising  after  all  danger  from  the  original 
attack  of  fever  seemed  over,  extensive  infiltration  and  burrowing  having 
caused  fatal  exhaustion.  If  the  pus  be  not  evacuated  promptly,  it  is  apt  to 
discharge  by  the  ear,  the  cartilaginous  meatus  being  separated  from  the  bone. 
I  have  rarely  known  deafness  to  jwrsist.  There  may  be  inflammatory  swell- 
ing of  other  glands,  analogous  to  the  buboes  of  the  plague. 

Meningitic  or  other  intracranial  lesions  are,  as  already  stated,  rare.  Palsies 
of  a  single  member,  or  even  paraplegia,  may  occur  among  the  sequels.  Nein'itis 
is  in  most  instances  the  cause. 

Jaundice,  erysipelas,  cancrum  oris,  and  abscesses  in  the  subcutaneous  tissues 
or  in  the  joints  are  occasional  complications. 

The  muscular  tissue  of  the  heart  is  affected  in  typhus  with  gramdar  degen- 
eration whenever  high  fever  is  present,  but  in  some  cases  this  lesion  is  so  extreme 
as  to  be  the  chief  cause  of  fatal  heart  failure  and  collaj)se,  Endo-  and  peri- 
carditis are  rare. 

The  hair  falls  out  after  typhus,  though  probably  not  so  frequently  as  alter 
typhoid.  Permanent  baldness  is  not  to  be  feared.  The  nails  j)r('sent  transverse 
ridges,  as  after  other  severe  acute  affections. 

Prognosis. — The  duration  of  tyj)hus  fever  i>,  im  an  averag(\  about  two 
weeks.  Short,  abortive  cases  are  occasionally  met  will",  in  which  the  crisis 
occurs  as  early  as  the  eighth  or  tenth  day.  On  the  other  hand,  the  lever  may 
be  prolonged  to  tiie  eighteenth  or  twenty-first  day,  and  if  serious  se(|uche  have 
developed  the  sickness  may  be  greatly  i)rotracte(i. 

The  mortality  varies  in  dilferent  epidemics  between  10  and  .'>")  \>iv  cciit. 
Tiie  type  of  the  disease  nnist  be  considered  in  estiniating  the  pidgiiosis,  as 
well  as  the  symptoms  of  the  individual  case,  ('hihh-cii  rarely  die;  ymiiig 
adults  have  many  chances  in  their  favnr;  beyond  the  age  oftlilrly  ilie  pni-im- 
sis  grows  more  grave,  and  after  middle  life  the  nmrlality  may  icaeli  •">(  •  |»<'r 
Vol..  I.— 10 


146  TYPHUS  'FEVER. 

cent.  Sex  exerts  no  influence.  The  previous  condition  and  habits  of  the 
patient,  and  especially  as  regards  privation  and  intemperance,  are  of  great 
impoi-tance :  the  disease  is  terribly  fatal  among  drunkards.  The  negro  race 
seems  to  succumb  readily  to  typhus  as  well  as  to  relapsing  fever. 

Intensity  of  the  nervous  symptoms ;  persistent  hyperpyrexia  ;  extreme  pros- 
tration and  rapid,  feeble  pulse,  with  threatened  heart  failure ;  scanty,  highly 
albuminous  urine;  vomiting  or  diarrhcea ;  copious  dark-colored  eruption, 
soon  becoming  petechial ;  pulmonary  complications, — these  are  most  unfavor- 
able elements  in  prognosis.  Typhus  is  noted,  however,  for  the  almost  miracu- 
lous recoveries  which  take  place  when  patients  seem  moribund,  so  that  our  efforts 
must  nev'er  be  relaxed  as  long  as  a  spark  of  life  remains. 

By  far  the  larger  proportion  of  deaths  occur  from  the  ninth  to  the  twelfth 
<lav.  In  very  grave  or  in  malignant  cases  the  system  is  overwhelmed  by  the 
toxaemia  even  as  early  as  from  the  first  to  the  fifth  day.  During  the  second 
Aveek  toxaemia,  exhaustion,  and  heart  failure  are  the  common  causes  of  death. 
When  a  fatal  result  occurs  after  the  close  of  the  second  week,  it  is  usually  from 
some  complication  or  sequel,  especially  pneumonia. 

True  relapses  are  excessively  rare  in  typhus,  and  second  attacks  or  recur- 
rences, though  not  unknown,  are  likewise  very  rare.  Patients  who  are  conva- 
lescing from  other  infectious  diseases  seem  highly  susceptible  to  the  poison  of 
typhus,  and  the  disease  is  very  dangerous  when  contracted  under  such  circum- 
stances. In  1865,  when  attending  a  large  number  of  cases  of  small-pox  and 
of  typhus,  I  saw  several  instances  where  each  of  these  diseases  developed  in 
patients  convalescing  from  the  other.  In  at  least  two  instances  I  could  not 
avoid  the  conclusion  that  I  had  been  the  medium  of  communicating  typhus 
to  patients  recovering  from  variola,  although  I  did  not  myself  contract  typhus 
until  the  following  year. 

Diagnosis. — Sporadic  cases  of  typhus  or  the  early  cases  of  an  ej)idemic  may 
be  mistaken  for  cerebro-spinal  fever,  for  typhoid,  or  for  measles.  This  is  partly 
because  typhus  is  a  much  more  rare  disease  than  any  of  the  others  mentioned,  so 
that  the  observer  is  off  his  guard.  But  even  in  the  midst  of  a  well -recognized 
epidemic  occasional  cases  present  themselves  where  the  diagnosis  is  difficult. 

In  1864  both  ty})hus  and  cerebro-spinal  fever  were  prevalent  in  Philadel- 
phia. Errors  of  diagnosis  were  frequently  made.  The  onset  in  both  diseases 
is  abrupt.  Fever  rises  rapidly  to  a  high  point ;  delirium  is  early  and  may  be 
violent.  Headache,  backache,  and  pains  in  the  limbs  occur,  and  hyperaesthesia 
is  often  present.  In  typhus,  though  not  nearly  so  often  as  in  meningitis,  there 
may  be  ])ainful  rigidity  of  the  muscles  of  the  nucha  with  retraction  of  the 
head.  The  headache  is,  however,  usually  more  intense  and  persistent  in 
cerebro-spinal  fever ;  muscular  soreness  and  rigidity,  and  especially  the 
retraction  of  the  head,  are  more  })ronounced  ;  intolerance  of  light  and  sound 
is  present ;  vomiting  is  much  more  common  ;  the  evidences  of  prostration  are 
less  marked,  and  especially  is  the  faihu^e  of  heart-power  later  and  less  con- 
stant; herpetic  eruptions  are  common,  while  the  characteristic  eruption  of 
typhus  is  wholly  wanting. 


TREATMEXT.  147 

In  ordiuarv  cases  of  typhoid  fever  there  is  littk^  or  no  danger  of  mistakinir 
it  for  typlius.  The  mode  of  onset,  the  absence  of  chill,  the  gradual,  step-like 
rise  of  temperature,  the  more  gradual  development  of  nervous  sytnptoms,  the 
bronchial  and  abdominal  symptoms,  the  marked  enlargement  of  the  spleen, 
the  occurrence  of  epistaxis,  and  the  postponement  of  the  eruption  until  the 
seventh  day,  serve  to  establish  the  diagnosis.  But  it  must  be  remembered 
that  in  typhoid  the  onset  is  sometimes  abrupt  and  the  rise  of  temperature  to 
a  high  point  early  and  rai)id  ;  that  intense  headache,  pains  in  the  limbs,  and 
liyperaesthesia  may  be  present;  the  delirium  be  early  and  active,  with  marked 
tendency  to  stupor ;  the  abdominal  symptoms  be  absent ;  and  the  erui>tion  be 
more  or  less  uniformly  converted  into  petechipe  and  acconijumicd  with  subcu- 
ticular mottling.  On  the  other  hand,  in  typhus  the  symptoms  may  be  mild, 
the  eruption  postponed  till  the  sixth  day,  and  then  be  scanty,  light-colonvl, 
and  disappear  wholly  on  pressure;  the  bowels  disposed  to  be  loose  and  the 
symptoms  of  prostration  be  largely  wanting.  In  short,  there  are  few  out- 
breaks of  typhus  in  which  some  cases  are  not  met  which  demand  cautious 
and  critical  study  before  the  diagnosis  can  be  established. 

The  eruption  of  typhus  comes  out  at  about  the  same  time  as  does  that  of 
measles,  and  at  first  may  resemble  it  considerably.  But  in  measles  the  erup- 
tive stage  is  preceded  and  attended  by  marked  catarrhal  symjitoms;  the  rash 
comes  out  first  on  the  face ;  the  spots  form  groups  with  crescentic  borders,  and 
rarely  become  petechial. 

The  bubo  plague  is  so  strictly  limited  to  certain  Oriental  coimtries  by 
modern  quarantine  that  the  question  of  its  differential  diagnosis  from  typhus 
can  rarely  arise.  The  symptoms  of  the  onset  are  not  dissimilar,  but  the  very 
rapid  development  in  the  j)lague  of  profound  typhoid  symptoms ;  the  early 
ai)pearance  of  buboes,  carbuncles,  and  extensive  petechiie  ;  the  pronounced 
tendency  to  collapse,  with  sudden  fall  of  temperature  ;  the  absence  of  the 
characteristic  eruption, — serve  to  distinguish  this  frightfully  fatal  disease 
from  typhus. 

It  is  unnecessary  to  repeat  here,  with  reference  to  the  possibility  ol'  mis- 
taking typhus  for  uraemia,  wliat  has  been  elsewhere  said  on  this  point  in  regard 
to  typhoid. 

Treatment. — The  highly  contagious  nature  of  typhus  fever  renders  imper- 
ative the  prompt  isolation  of  each  case.  The  infected  house  should  be  vacated 
and  thoroughlv  cleansed  and  disinfected.  If  a  case  has  occurred  in  a  large 
conununity,  the  public  health  authorities  are  to  be  summoned  to  take  charge 
of  the  locality,  with  a  view  to  the  adoption  of  sucii  radical  sanitMry  measures 
as  mav  prevent  any  spread  of  the  disease.  Patients  sulTering  with  typhus 
fever  should  not  be  admitted  to  general  hospitals  if  it  can  be  avoided,  but 
should  be  accommodated  in  special  hosi)itals  for  infections  diseases,  if  the 
climatic  conditions  are  favorable  and  the  cases  are  numerous,  they  aiv  best 
treated  in  isolated  tents. 

The  hygiene  of  the  sick-room  as  regards  nursing,  rigid  cleanliness,  venti- 
lation, disinfecti(m  of  all  clothing,  demands  specially  close  altenli..i..    Allimugh 


148  TYPHUS  FEVER. 

there  arc  no  grave  lesions  of  the  alimentary  tract,  and  though  there  may  be 
some  maintenance  of  appetite,  it  is  on  the  whole  safer  that  the  diet  should  be 
li(piid  throughout  the  course  of  the  disease.  Milk  is  the  best  basis,  and  to  it 
mav  be  added  strong  animal  broths.  Junket,  thin  arrowroot,  light  custard, 
and  raw  egg  may  be  cautiously  tried,  and  continued  if  found  to  agree.  Tea 
or  coffee,  either  black  or  with  hot  milk,  may  be  taken  with  relish,  and  may 
be  very  nsel'ul,  especially  where  there  is  a  tendency  to  ataxic  symj)toms  or  to 
stupor.  Nourishment  should  be  given  in  comjiaratively  small  quantities  at 
short  intervals :  four  to  six  ounces  of  milk  or  its  equivalent  every  two  hours 
may  be  taken  as  a  fair  standard.  Water  should  be  offered  frequently,  and  the 
patient  may  be  encouraged  to  drink  it  freely.  Alcohol  is  indicated  in  nearly 
all  cases  bv  the  prostration  and  the  tendency  to  heart  failure.  It  is  specially 
well  borne  in  childhood  and  in  advanced  life.  Cases  of  moderate  severity  in 
vigorous  young  adults  often  do  well  without  it.  The  same  rules  are  to  be 
observed  as  to  administration  and  as  to  deciding  for  or  against  its  beneficial 
action  as  were  laid  down  in  the  article  on  Typhoid  Fever.  Upon  the  whole, 
it  is  needed  in  ty}>hus  earlier,  more  constantly,  and  more  freely  than  in 
tvphoid.  It  is  usually  well  to  begin  with  small  amounts  much  diluted,  but 
the  remedy  mu!?t  be  unhesitatingly  pushed  if  the  symptoms  call  for  it.  I  find 
among  my  notes  the  records  of  two  cases  where  one  and  a  lialf  ounces  of 
strong  brandy  were  given  every  hour,  day  and  night,  for  ninety-two  and 
ninety-six  hours  respectively,  with  the  manifest  effect  of  saving  life. 

The  presence  of  marked  ataxic  or  adynamic  nervous  symptoms,  a  copious 
and  dark  eruption  with  abundant  petechise,  a  small,  weak,  and  rapid  pulse  with 
failing  cardiac  impulse  and  first  sound,  are  the  positive  indications  for  stimula- 
tion :  the  effect  of  the  stimulus  upon  the  symptoms  is  the  guide  as  to  the 
proper  amount  to  administer,  and  the  fact  that  the  disease  runs  a  short,  self- 
limited  course  justifies  the  freest  use  of  stimuli  to  carry  the  patient  along  till 
the  critical  hour  is  reached. 

The  management  of  the  fever  should  be  upon  the  same  general  lines  as  in 
typhoid.  The  use  of  cold  baths,  systematically  employed  after  the  Brand 
method,  should  be  insisted  upon  in  all  cases  where  the  fever  rises  to  103°  in 
the  axilla  or  103|°  in  the  rectum.  While  the  temperature  remains  below  that 
point  dependence  may  be  placed  upon  repeated  sponging  with  cold  water  or  an 
occasional  pack.  Should  the  surroundings  of  the  case  render  bathing  imprac- 
ticable, it  will  of  course  be  necessary  to  rely  on  repeated,  thorough  cold-water 
packs  or  affusion  as  originally  used  by  Currie.  It  will,  however,  soon  be  pos- 
sible to  secure  portable  bath-tubs  by  means  of  which  hydrotherapy  can  be 
carried  out  in  private  houses  of  every  class.  It  is  of  the  utmost  importance 
that  the  temperature  should  be  controlled  from  the  very  first  day.  If  this 
be  judiciously  and  firmly  done,  the  development  of  the  gravest  nervous  symp- 
toms and  of  alarming  heart  failure  may  often  be  averted.  The  most  fre- 
quent cause  of  failure  of  hydrotherapy  is  its  postponement  until  heart,  brain, 
and  blood  have  been  too  seriously  damaged  by  the  continuance  of  high  tem- 
perature. 


TREATMENT.  149 

Antipyrine  and  analogous  antipyretics  must  be  used  with  extreme  caution. 
A  sudden  rise  of  temperature  may  be  met  and  modifieil  by  one  or  two  medium 
doses,  but  in  typluis,  even  more  tlian  in  typhoid,  there  is  a  tendency  to  contin- 
uous high  temperature,  and  anything  lilvc  the  continuous  use  of  these  antipy- 
retics is  absolutely  forbidden. 

The  mineral  acids,  especially  nitro-muriatic  and  phosphoric,  may  be  used 
freely  with  advantage.  There  is  no  good  ground  for  believing  that  they  exert 
any  specific  effect  on  the  virus  of  the  disease,  but  their  general  and  local 
action  is  tonic.  Besides,  when  properly  diluted  they  make  a  pleasant  acidulated 
drink,  so  that  the  ]nitient  is  encouraged  to  take  water  freely.  Dilute  cidorine- 
water  may  be  used  in  the  same  wav. 

Headache  may  often  be  relieved  by  applications  of  cold  to  the  head,  but  if 
intense  and  persistent  it  may  require  the  use  of  sedatives.  Small  doses  of 
mor])hine  and  atrojiine  may  be  given  safely  by  hypodermic  injection,  or 
opium  may  be  used  by  the  rectum  or  by  the  mouth. 

^yhen  active  delirium  is  present,  with  sleeplessness  and  severe  headache,  an 
opiate  combined  with  cannabis  Indica  or  with  hyoscine  hydrobromate  is  to  be 
tried;  under  these  circumstances  Graves  advised  tartar  emetic  in  conjunction 
with  opium.  Chloral  hydrate,  in  doses  of  12  to  15  grains  by  the  mouth  or 
of  20  grains  by  enema,  has  given  good  results.  If  insomnia,  with  or  without 
headache,  is  associated  with  marked  prostration  and  ataxia,  remedies  such  as 
camphor,  valerian,  or  asafoetida  are  of  use'  and  may  have  a  small  amount  of 
o])ium  associated  with  them.  Full  doses  of  quinine  and  asafoetida,  10  gi'ains 
each,  in  the  form  of  suppository,  given  morning  and  evening,  exert  a  support- 
ing and  quieting  effect. 

If  irritability  of  the  stomach  and  \niniting  are  present,  they  must  be 
relieved  by  simple  sedative  remedies  and  restriction  of  food,  with  substitution, 
if  necessary,  of  nutritious  enemata.  Constipation  may  call  for  the  use  of  gly- 
cerin suppositories  or  of  simple  enemata,  or  for  the  internal  administration  of 
fractional  doses  of  calomel  or  mild  saline  aperients.  A  careful  watch  must  be 
maintained  against  comj)lications. 

I^dmonary  congestit)n  or  catarrh,  if  moderate  in  degree,  may  be  relieved 
by  dry  cups  or  by  counter-irritation  applied  to  the  back  of  the  chest.  If  nmre 
severe,  or  if  ])neumonia  has  developed,  increased  stimulation,  annnonium  car- 
bonate, and  strychnine  should  be  directed.  I  have  used  turpentine  with  much 
aj)|)arent  advantage  when  the  typhoid  state  became  fully  developed,  with  great 
nervous  prostration,  feeble  circulation,  and  marked  ]»ulmc)nary  congcvtion. 
Strychnine  should  be  used  in  the  same  manner  and  to  meet  the  same  indica- 
tions as  in  typhoid  fever.  More  reliance  is  to  be  placed  on  it  and  alcohol  than 
on  digitalis  in  the  treatment  of  threatened  heart  failure. 

Convalescence  is  retarded  by  few  sequels,  and  iclapses  do  not  occur.  Care 
should,  however,  be  observed  both  as  to  tli«t  mid  exercise.  The  amount  of 
stimulant  should  be  reduced  as  nipidly  as  possible,  and  a  bitter  tonic  with  iron 
may  be  substituted  with  advantage. 


RELAPSING   FEVER. 

By  WILLIAM  PEPPER. 


Definition. — Relapsing  fever  is  an  acute  infectious  and  contagious  epi- 
demic disease,  characterized  by  its  division  into  successive  stages  of  exacer- 
bation and  intermission,  by  various  uniform  alterations  in  the  viscera,  and  by 
the  constant  presence  in  the  blood  of  a  specific  micro-organism — the  spirillum 
of  Oberme}'er. 

Synonyms. — It  has  many  synonyms,  the  chief  of  which  are — Riickfalls 
typhus,  Febris  recidiva  vel  recurrens,  Fievre  a  rechutes.  Bilious  typhoid  fever, 
Hunger-pest,  and  Spirillum  fever. 

History. — While  it  is  certainly  a  fact  that  the  disease  existed  prior  to  that 
date,  the  first  clear  account  of  it  was  written  in  1739.  Since  then  numerous 
outbreaks  have  from  time  to  time  occurred  in  various  parts  of  the  world.  Its 
first  appearance  in  America  of  which  we  have  any  certain  knowledge  occurred 
in  1844,  when  it  was  imported  by  the  passengers  on  an  emigrant-ship.  After 
this  a  few  cases  were  observed  in  this  country,  and  in  1869  an  epidemic  of  the 
disease  prevailed  in  Philadelphia.  I  had  the  opportunity,  in  conjunction  with 
my  colleague,  the  late  Edward  Rlioads,  to  study  several  hundred  cases  which 
were  admitted  to  our  wards  at  the  Philadelphia  Hospital.  Since  that  time 
other  epidemics  have  occurred,  the  last  of  any  considerable  size  having  been 
located  in  Russia  during  the  years  1885  and   1886. 

Etiology. — The  etiology  of  relapsing  fever  is  not  as  yet  entirely  clear,  but 
for  reasons  that  will  be  more  fully  stated  below  it  is  certain  that  the  spirilhun 
of  Obermeyer  plays  an  important,  if  not  the  chief,  part.  Aside  from  this 
immediate  cause,  we  have  numerous  factors  important  in  their  influence  upon 
the  existence  and  spread  of  the  disease. 

Chief  among  the  predisposing  causes,  although  not  essential,  is  the  presence 
of  the  combination  of  filth  and  starvation.  The  former  of  these  is  usually 
associated  with  overcrowding,  itself  a  powerful  predisjiosing  cause  aside  from 
its  importance  in  effecting  the  spread  of  the  disease  and  widening  the  limits  of 
the  affected  area;  while  all  three  factors — filth,  famine,  and  overcrowding — 
make  a  combination  pro-eminontly  calculated  to  reduce  the  vital  foi'ce  of  both 
individual  and  community,  thereby  offering  favorable  conditions  for  the  onset 
and  S])read  of  this  as  of  any  other  general  disease.  That  filth,  overcrowding, 
and  starvation  are  not  necessary  factors  is  shown  by  the  fiict  that  those  in  the 
entirely  oj>posite  condition  may  be,  and  often  are,  attacked. 

A  still  more  essential  and  ever-necessary  factor  is  contagion.  Tliis  may 
take  place  either  by  direct  contact  of  the  well  with  the  sick,  or  the  contagious 

150 


ETIOLOGY.  151 

])rinciple  may  be  carried  by  foniites,  as  is  well  evidenced  by  the  frequent 
occurrence  of  the  disease  among  laundresses.  The  infecting  material  may  be 
transported  from  the  ill  without  the  bearer  contracting  the  disease,  although 
communicating  it  to  others. 

Neither  age  nor  sex  has  any  manifest  bearing  upon  the  etiology  of  this  dis- 
ease, although,  as  would  be  expected  from  the  greater  exposure  to  infection, 
the  male  sex  and  the  active  or  middle  ]HM-iod  of  life  furnish  the  greater  num- 
ber of  cases. 

Race  would  seem  to  have  no  predisposing  or  protective  iuHuence,  save  only 
in  so  far  as  the  hygienic  surroundings  and  j)I\ysical  condition  of  ditfcrcnt 
nations  may  alter  the  relative  resistance  to  contagion.  The  negro  shows,  pos- 
sibly, somewhat  greater  susceptibility  to  the  poison  than  do  other  races.  Tiiis 
liability  is  not  strongly  marked — not  more  so  than  we  M'ould  expect  when  we 
remember  the  susceptibility  of  this  class  to  various  other  diseases  of  a  some- 
what similar  character. 

Season  has  no  evident  etiological  relation  to  the  onset  of  the  disease,  nor  do 
climatic  conditions  favor  or  limit  its  power,  save  for  the  wide  variation  in 
habits  of  life  and  surroundiny-s  amon";  the  dwellers  in  different  climates. 

By  far  the  most  important  etiological  factor  is,  however,  the  minute  sjiiral 
organism  discovered  by  Obermeyer  in  1873 — the  spirillum  Obermeicri.  This 
has  been  found  so  constantly  in  the  blood  of  patients  suffering  from  this  dis- 
ease that  suspicion  pointed  strongly  toward  it  as  the  cause  before  its  successful 
cultivation  on  artificial  media  and  inoculation  into  anituals.  The  micro- 
organisms are  long,  extremely  delicate,  fibre-like  bodies  of  spiral  shape,  in 
length  measuring  about  six  or  seven  times  the  diameter  of  a  red  blood-cell. 
(See  Fig.  11.)    They  move  freely  about  in  the  field  of  the  microscope,  causing 


oo; 


Fig.  11. 


c8o?)Og#       o 

o  ^ 

Recurrent  Spirals  in  the  Blood  fafler  .laksch). 

disturbance  of  the  blood-cells.  This  spiral  motion  takes  place  in  the  dircH-ti..n 
of  the  length  of  the  organism.  Dried  preparations  ..f  tlic  Mh.hI  ...ay  be  read- 
ily stained  bv  the  ordinary  a.iilinc  coloi-s  in  o.-dcr  to  sl...\v  the  i)arasilc.  Net 
only  has  it  been  found  in  "the  blood  ol.tainc.1  dirc.-tly,  but  ih<-  organis...  is  also 
present  in  the  menstrual  l,loo<l,  in  tlint  coughed  up.  an.l  in  that  pM-cl  by 
the  urethra;  but  has  never  been  runnd  in  thr  urinr.  ^aliva.  ...ilk,  s\v:.t,  ..r 
in  lym])h  from  vesicles. 


152  RELAPSING    FEVER. 

From  the  researches  of  numerous  observers  it  is  proved  beyond  peradven- 
ture  that  during  the  febrile  access  the  spirilla  are  very  numerous  in  the  blood, 
while  during  the  apyretic  stage,  or  after  the  subsidence  of  an  attack  wherein 
but  one  pyretic  period  occurs,  the  organisms  are  found  to  be  either  totally 
absent  or  present  in  but  very  inconsiderable  number.  The  question  of  the 
habitat  of  the  spirilla  during  the  apyretic  intervals  is  one  of  deep  interest,  and 
not  yet  fully  determined,  although  the  experiments  of  Metschnikoff  upon  apes, 
in  which  the  disease  had  been  produced  by  inoculation,  would  indicate  that 
the  organisms  retired  to  the  spleen  with  the  subsidence  of  pyrexia.  Sarnow 
and  v.  Jakscli  found  in  the  blood,  examined  just  prior  to  an  exacerbation, 
numerous  highly  refracting  forms  resembling  diplococci.  These  immediately 
upon  the  beginning  of  the  attack  developed  into  short,  thick  rods,  from  which 
the  spirilla  were  formed.    These  bodies  may  possibly  be  the  spores  of  the  parasite. 

As  mentioned  above,  the  pathogenic  organism  has  been  injected  into  apes 
with  the  result  of  producing  the  disease  in  the  animals  so  inoculated.  Ac- 
cidentally, by  cuts  at  autopsies  and  other  means,  the  disease  has  been  contracted 
by  man  in  a  similar  manner,  except  for  the  fact  that  in  these  cases  not  only 
the  micro-organisms,  but  also  other  material,  were  brought  into  the  body.  It 
can,  theref  »re,  be  asserted  as  proven  that  this  disease  is  produced  by  a  specific 
micro-organism  constantly  present  in  large  numbers  in  the  blood  during  the 
periods  of  pyrexia,  disappearing  from  the  blood  with  crisis,  capable  of  being 
cultivated  upon  artificial  media,  and  of  producing  the  disease  when  inoculated 
in  pure  culture. 

Morbid  Anatomy. — The  external  surface  of  the  body  shows  no  character- 
istic changes,  although  jaundice  is  seen  where  that  symptom  was  present  during 
life.  I  noticed  in  the  cases  at  the  Philadelphia  Hospital  that  where  the  fatal 
result  came  during  the  pyretic  period  the  cadaver  retained  its  heat  for  a 
remarkably  long  time.  Emaciation  is  not  marked  or  is  wdiolly  absent, 
depending  somewhat  upon  the  duration  of  the  illness. 

Upon  section,  the  muscles  are  frequently  found  to  be  jaundiced,  but  only 
where  icterus  was  one  of  the  symptoms  before  death.  The  voluntary  muscles 
are  often  fiabby,  and  under  the  microscope  are  found  to  have  undergone  granu- 
lar degeneration.     Interfascicular  hemorrhages  may  be  present. 

The  blood  shows  one  other  peculiarity  besides  the  presence  of  the  micro- 
organism :  niunbers  of  granular  cells  are  seen  among  the  proper  blood-cells. 
These  may  possibly  be  accounted  for  by  the  stripping  off  of  the  endothelial 
colls  of  the  intima  of  blood-vessels,  as  was  observed  most  markedly  by  Pusch- 
kareff  in  his  observations  upon  the  pathology  of  the  disease  in  Russia. 

The  pericardium  may  show  no  abnormal  change,  or  we  may  find  pericar- 
ditis or  subpericardial  lueraorrhagic  extravasation. 

The  heart  in  fatal  eases  is  usually  found  seriously  aflFected,  the  muscular 
tissue  being  of  a  grayish  color  and  softened,  while  under  the  microscope  the 
muscle-fibres  are  found  to  have  undergone  a  similar  change  in  greater  or  less 
degree.  As  would  be  expected,  this  granular  change  is  most  marked  in  cases 
of  long  duration. 


MORBID   ANATOMY.  153 

There  are  no  valvular  lesions  save  those  due  to  a  preceding  illness.  Beneath 
the  endocardium  there  may  often  be  found  hffimorrhauic  effusions. 

Pleurisy  is  frequently  present,  usually  in  combination  with  pneumonia. 
Subpleural  ecchymoses  are  common.  In  the  ui)per  air-passages  there  has 
been  noted  the  presence  of  catarrhal  inflammation,  while  in  some  cases  a 
diphtheritic  exudate  has  been  found  in  the  pharynx  and  larynx.  (Edema 
of  the  glottis  may  be  present.  Lobar  pneumonia  is  a  frequent  lesion  found 
upon  post-mortem  examination  of  fatal  cases  of  relapsing  fever,  and  in  the 
lungs,  as  in  many  other  portions  of  the  body,  haimorrhagie  infarctit)ns  are  by 
no  means  rare.  In  one  case  in  my  c»wn  experience  an  area  of  gangrene  of  the 
lung  occurred  as  the  termination  of  a  complicating  lobar  pneumonia. 

True  metastatic  purulent  foci  may  be  present.  The  bronchial  glands  show 
no  special  alterations  save  those  due  to  any  pulmonary  condition  that  happens 
to  be  present. 

The  peritoneum  may  show  signs  of  local  inflammation  (chiefly  in  the 
splenic  region),  or  there  may  be  a  general  peritonitis,  as  in  cases  of  rupture 
of  the  spleen. 

In  neither  the  stomach  nor  the  intestinal  tract  are  there  any  characteristic 
lesions,  although  submucous  ecchymoses  and  extravasations  are  frequently  dis- 
covered. The  special  glandular  apparatus  of  the  gastric  and  intestinal  mucous 
membrane  shows  no  chamre,  the  solitarv  and  agminated  <>;lands  of  the  intestine 
presenting  less  swelling  and  congestion  than  is  usually  found  in  other  infectious 
diseases.    The  abdominal  lynq)hatic  glands  show  no  pronounced  morbid  changes. 

The  spleen  is  constantly  and  characteristically  altered,  with  more  definite 
and  specific  changes  than  any  other  organ  exhibits.  It  is  always  large,  usually 
adherent  to  the  diaphragm,  and  almost  always  partly  covered  by  fresh  fibrinous 
exudation.  The  size  of  the  spleen  is  quite  variable,  the  limits  in  the  series 
of  cases  observed  by  me  being  10  and  44J  ounces.  The  capsule  often  presents 
a  mottled  appearance,  or  may  actually  have  in  its  substance  large  ]>uri)le 
ecchvmotic  areas.  In  a  few  cases  rupture  of  the  capsule  has  been  found. 
The  splenic  pulp  is  usually  more  or  less  softened  and  swollen,  and  shows 
enlarged  Malpighian  bodies.  The  latter  may  vary  somewhat  in  character 
with  the  stage  of  the  disease  at  which  death  occurs.  \n  the  early  stages  they 
are  enlarged  and  of  a  greenish-yellow  color,  giving  to  the  cut  surface  very 
much  the  appearance  of  shad-roe.  Later  in  the  disease  this  enlargement  still 
further  increases,  until,  by  coalescence  or  aggregation  of  neighboring  cor]>nscles, 
laro-e  masses  raav  be  formed.  Iliemorrhagic  infarction  of  the  spleen  is  very 
frequent,  the  infarcts  being,  as  a  rule,  venous,  and  freciuently  breaking  down 
into  purulent,  softened  areas. 

These  enlarged  Mali)ighiau  corpuscles  are  fouinl,  upon  microscopical 
examination,  to  be  composed  of  large  nundx'rs  of  small  lymphoid  cells 
which  have  undergone  cloudy  swelling,  or.  l;it<r  in  the  disease,  marked  fatty 
degeneration.  The  splenic;  pulp  is  found  to  consist  (-f  large  numbers  of 
lymphoid  cell-elements  in  a  mon;  or  less  |u-onoiinced  state  of  gnimilar  degen- 
eration, free  red-blood  corpuscles,  and  (ibroiis  tissue. 


154  RELAPSING    FEVER. 

Tlie  liver  is,  in  the  vast  majority  of  eases,  enlarged,  frequently  much  con- 
gested, at  times  pale  and  mottled  in  appearance.  Ecchymotic  areas  beneath 
the  capsule  and  extending  for  a  short  distance  into  the  liver-tissue  proper  are 
met  with,  as  in  the  case  of  the  spleen.  The  hepatic  substance  is  usually  soft- 
ened, but  may,  on  the  other  hand,  be  found  to  be  more  firm  than  normal. 
The  parenchymatous  cells  of  the  liver  are  commonly  in  a  state  of  cloudy 
swelling  or  of  fatty  infiltration.  The  capillaries  of  the  organ  are  stuffed 
with  blood  during  the  febrile  stage,  but  regain  almost,  if  not  quite,  their 
normal  size  during  the  apyretic  period.  In  the  cases  accompanied  by  jaun- 
dice the  hepatic  cells  contain  brownish  granules.  Various  changes  in  the 
hepatic  interstitial  tissue  are  found,  but  these  usually  depend  upon  pre- 
viously-existing disease,  and  are  not  constant.  The  smaller  biliary  canals 
within  the  liver  are  at  times  found  to  be  entirely  patulous,  but  their  epi- 
thelial cells  may  present  a  swollen,  granular  appearance,  with  scarcely  visible 
nuclei,  or  in  the  cases  of  most  intense  jaundice  the  lumen  of  the  ducts  may 
be  entirely  occluded.  The  larger  bile-ducts  present  no  changes  of  sufficient 
gravity  to  account  for  the  icterus  that  is  so  often  present  in  this  disease. 

The  gall-bladder  is,  as  a  rule,  found  to  be  filled  with  dark  bile,  but  that 
the  latter  is  capable  of  passing  through  the  ducts  is  shown  by  the  presence  of 
bile-pigment  in  the  contents  of  the  duodenum  and  in  the  fseces. 

The  pancreas  and  suprarenal  capsules  show  no  peculiar  alteration. 

The  kidneys  are  usually  found  to  be  moderately  enlarged,  at  times  of  a 
mottled  appearance  or  with  actual  hsemorrhagic  extravasations  beneath  the 
capsule.  Hsemorrhagic  infarcts  are  met  with  in  a  small  proportion  of  cases, 
and  at  times  puriform  collections  are  found  near  the  periphery.  In  a  large 
proportion  of  cases  true  parenchymatous  nephritis  is  found,  but  in  how  many 
this  is  merely  an  acute  engrafting  upon  former  chronic  process  it  is  difficult  to 
determine.  According  to  W.  Puschkareff,  the  kidneys  always  show  the 
appearance  of  a  parenchymatous  affection,  and  a  not  highly  pronounced  acute 
glomerulo-nephritis  is  also  a  constant  accompaniment  of  relapsing  fever. 
Bloody  extravasation  into  Bowman's  capsule  has  been  noted  by  some 
authors. 

As  already  incidentally  mentioned,  there  has  been  found  a  peculiar  swelling 
and  stripping  up  of  the  endothelial  cells  of  the  blood-vessels  in  some  organs, 
notably  in  the  spleen.  The  cause  of  this  process  it  is  difficult  to  assign,  but 
it  may  be  that  one  of  its  results  is  the  large  number  of  infarcts  found  so 
widely  distributed  in  some  of  the  cases.  The  bone-marrow  shows  peculiar 
alterations,  in  that  the  lymphoid  elements  are  markedly  increased  in  number 
and  degenerated,  so  that  in  the  ends  of  the  long  bones  there  are  at  times 
found  cavities  with  puriform   contents. 

Symptomatolog'y. — The  incubation  period  extends  over  from  five  to  eight 
days,  during  which  the  individual  may  suffer  from  vague  pains  and  slight 
malaise.  At  the  end  of  the  time  mentioned  there  is  an  abrupt  onset,  with  chill, 
and  aching  pain  in  the  head,  back,  and  limbs.  The  chill  may  be  pre- 
ceded by  obstinate  vomiting  or  vertigo.     There  is  marked  physical  depres- 


S  YMPTOJIA  TOL  O G  Y.  1 55 

sion,  with  distress,  and,  possibly,  tenderness  in  the  epigastric  region.  The 
temperature  rapidly  rises  after  the  occurrence  of  the  chill,  or  even  during  its 
continuance,  while  the  muscular  pains  continue  to  be  very  severe.  The  rise  is 
usually  very  abrupt,  reaching  in  some  cases  105°  or  10G°  F,  within  the  first 
twenty-four  hours.  With  the  rise  in  temperature  the  pulse  becomes  very 
rapid,  averaging  about  110  beats  per  minute,  and  is  full  and  bounding.  While 
the  attack  of  pyrexia  is  in  progress  the  face  is  usually  flushed,  and  in  some 
cases  may  present  a  bronzed  appearance,  or  icterus  may  be  present  and  hide 
the  appearances  just  noted.  There  is  no  eruption  characteristic  of  the  disease, 
but  sudamina  are  very  numerous,  and  in  some  epidemics  purpuric  spots  have 
been  noted.  The  conjunctivae  are  usually,  but  not  invariably,  clear,  except  in 
cases  presenting  jaundice.  The  tongue  is  coated  white  over  the  dorsum,  with 
clean  red  borders  and  triangular  area  at  the  tip. 

During  this  stage  the  cephalalgia,  which  is  usually  either  frontal  or  general, 
persists.  Delirium,  except  in  alcoholic  subjects,  is  but  rarely  present,  but 
extreme  wakefulness  is  a  very  common  and  annoying  symptom,  and  is  over- 
come by  drugs  only  with  extreme  difficulty.  Convulsions  are  rare,  but  may 
occur  in  cases,  even  though  not  accompanied  by  albuminuria. 

Besides  the  muscular  pains  above  mentioned,  there  is  great  hyperaesthesia, 
with  marked  tenderness  over  the  position  of  the  nerve-trunks  and  endings. 
Another  common  sym])tom  connected  with  the  nervous  system  is  a  ]H'culiar 
tindino-  of  the  extremities.  Occasionallv  motor  palsy  is  observed,  but  its 
occurrence  is  rare. 

Thirst  is  usually  intense,  while  there  is  extreme  repugnance  toward  the 
taking  of  nourishment.  Nausea  and  vomiting  are  prominent  symptoms,  the 
matters  vomited  at  times  containing  blood.  The  state  of  the  bowels  is  very 
variable,  although  some  constipation  is  usually  present.  Tympanites  is  not  a 
marked  or  by  any  means  constant  symptom.  Abdominal  pain  is  one  of  the 
most  prominent  subjective  symptoms,  and  is  usually  situateil  in  the  epigastric 
and  splenic  regions.  There  is  also,  as  a  rule,  decided  tenderness  on  i>ressure. 
The  areas  of  hepatic  and  splenic  dulness  are  invariably  increased  during  this 
pyrexial  stage,  the  latter  being  more  markedly  enlarged  than  the  former. 

There  is  usually  some  annoying  cough,  and  epistaxis  may  be  (piitc  t.bsti- 
nate.  Examination  of  the  chest  during  this  stage  may  be  negative,  but  there 
are  .usually  present  the  signs  of  acute  bronchitis  or  even  of  pulmonary  conges- 
tion, with'some  impairment  of  resonance  at  the  bases.  There  is  frequently  to 
be  heard  a  hsmic  murmur  over  the  cardiac  region,  but  no  other  nnn-nuirs  arc 
developed  as  a  result  of  the  disease. 

The  urine  is  concentrated  and  iiigh-colorcd,  bile-stained  in  the  cases  with 
icterus,  and  may  contain  blood.  As  before  stated,  wh.iv  liaMuatuiia  is  present 
the  spirilla  mav  be  found  in  the  urine. 

The  condition  above  described  persists,  the  temperature  varying  but  bttle 
from  dav  to  dav,  until  the  crisis,  wbi.-ii  usually  .M-eiirs  in  ab<.iit  six  cr  seven 
days.  Just  preceding  this  event  there  is  fre(iuently  a  mark.^l  v^^v  „,  tlw  body- 
temperature  to  a  point  even  higher  than   (hal  ,.nvinnsly  attained.      I  h,-  ens.s 


156  RELAPSING   FEVER. 

is  sio-nalized  by  a  rapid  fall  in  the  temperature,  a  less-marked  fall  in  the  pulse- 
rate  a  cessation  of  many  of  the  most  distressing  symptoms,  and,  as  a  rule,  the 
occurrence  of  some  critical  discharge — a  profuse  outpouring  of  sweat,  a  free 
flow  of  urine,  a  copious  stool  or  a  series  of  bowel  movements,  epistaxis,  or, 
more  rarelv,  metrorrhagia.  During  the  occurrence  of  the  crisis  the  face 
becomes  pale  unless  icterus  mask  all  pallor.  The  crisis  may  extend  over 
as  much  as  several  hours,  the  temperature   in   that  time  falling  6°,  8°,  or 

even  14°  F. 

The  patient  then  enters  upon  a  period  of  apyrexia,  the  intermission.  During 
this  stao-e  most  of  the  more  distressing  symptoms  are  absent :  the  temperature 
remains  subnormal  for  a  day  or  two  before  regaining  the  level  of  health ;  the 
pulse-rate  diminishes,  but  not  to  an  extent  commensurate  with  the  fall  in  tem- 
perature;  the  pulse  loses  its  bounding  character,  but  becomes  easily  excited ; 
the  cephalalgia  becomes  less  intense,  although  the  muscular  pain  and  soreness 
continue  to  be  severe.  During  this  time,  it  is  to  be  remembered,  but  few  or 
no  spirilla  are  to  be  found  in  the  blood. 

The  disease  in  some  cases  ceases  after  one  attack,  the  patient's  condition 
merging  from  that  of  the  post-critical  period  into  that  of  convalescence ;  but 
usually  after  an  apyretic  interval  of  six  or  seven  days  (the  extreme  limits 
beino-  two  and  twenty)  a  relapse  occurs  resembling  in  its  onset  the  first  attack 
described  above.  The  relapse  diifers  from  the  primary  pyretic  period  in  but 
few  ]iarticulars.  The  patient's  general  condition  is  not  so  favorable,  owing  to 
the  fiict  that  the  attack  occurs  in  a  system  already  weakened  by  fever;  but, 
fortunately,  the  second  attack  is  not,  as  a  rule,  aceom])anied  by  such  high 
fever  and  such  intense  cephalalgia,  nor  is  it  of  such  long  duration  as  was 
that  with  which  the  illness  began. 

The  first  relapse  (second  pyrexial  period)  continues,  on  an  average  for  from 
three  to  four  days,  tiie  extremes  being  a  few  hours  and  seven  days.  With  the 
beginning  of  this  second  pyrexial  attack  the  spirilla  reappear  in  the  blood,  to 
again  disappear  with  the  second  crisis.  In  the  great  majority  of  cases  the 
morbid  process  terminates  after  the  first  relapse,  but  two,  three,  four,  or  even 
so  many  as  eight,  relapses  may  occur.  The  duration  of  the  disease  may  thus 
extend  to  eighteen  or  twenty  days,  all  told,  where  a  single  relapse  has  occurred, 
up  to  ninety  or  even  more  days  in  cases  with  multiple  relapses. 

During  an  attack  such  as  has  been  described  certain  other  symptoms. and 
conditions,  more  or  less  deserving  of  the  name  of  complications,  may  occur. 
These  demand  a  more  detailed  examination. 

Delirium,  that  at  times,  though  infrequently,  occurs,  may  be  of  different 
kinds.  Although  the  temperature  may  remain  at  a  great  height,  the  mental 
condition  is  much  clearer  than  is  usually  observed  in  cases  of  either  typhus  or 
typhoid  fever,  in  which  the  thermometer  indicates  so  high  a  degree.  There 
may,  however,  appear  in  alcoholic  subjects  a  delirium  that  is  active  and  almost 
maniacal.  On  the  other  hand,  there  may  be  present  a  low,  muttering  delirium 
in  the  cases  that  assume  the  so-called  typhoid  character. 

Sometimes  in  the  first  intermission — or,  more  rarely,  at  other  times — there 


COMPLICATIONS  AXD    SEQCIJL.E.  157 

occurs  a  sudden  rise  of  temperature  without  any  appreciable  cause.  This  uiav 
in  some  cases  be  due  to  the  influence  of  embolism  of  some  important  organ. 
During  the  period  succeeding  crisis,  when  the  temperature  should  maintain  a 
normal  or  even  subnormal  course,  we  may  have  a  continuance  of  febrile  mt)ve- 
ment.  This  is  usually  due  not  to  the  continuance  of  the  influence  of  the 
specific  poison,  but  to  the  continuing  irritation  of  some  organ  or  tissue 
secondarily  involved.  The  local  peritonitis  in  the  splenic  region  may  well 
be  suflRcient  to  maintain  a  considerable  elevation  of  temperature. 

Complications  and  Sequelae, — Of  complications,  lobar  pnciunonia  stands 
well  to  the  front  as  being  the  most  frequent  cause  of  death.  In  the  St.  Peters- 
burg epidemic  of  1885-86,  Puschkareif  found  this  lesion  present  in  18  out  of 
47  cases  examined.  A\'hile,  however,  this  complication  is  one  of  the  most  fre- 
quent immediate  causes  of  death,  its  presence  does  not  necessitate  a  fatal  i)rog- 
nosis.  With  hepatization  of  the  lung-tissue  there  is  usually  associated  plas- 
tic pleurisy,  and  at  times  pericarditis.  Gangrene  of  the  lung  may  terminate 
the  course  of  a  complicating  lobar  pneumonia.  So  numerous  arc  the  exam- 
ples of  pulmonary  congestion  that  that  condition  scarce  merits  the  nanie  of 
a  complication,  as  it  seems  to  be  a  part  of  the  ensemble  of  a  severe  case  of 
relapsing  fever,  just  as  it  is  in  typhoid  fever  and  other  diseases  of  asthenic 

type. 

In  some  epidemics  grave  catarrhal  laryngitis  has  been  a  frequent  complica- 
tion, while  cases  with  a  diphtheritic  deposit  in  the  ujiper  air-passages  have 
been  recorded.  ICpistaxis  may  be  sufficiently  severe  to  require  ]>lugging  of  the 
nares,  and  may  vastly  increase  the  anasmia  so  prone  to  occur  in  the  ordinary 
course  of  the  disease. 

Pericarditis  is  not  a  frequent  com])lication,  but  is  met  with  occasionally, 
being  usually  an  accompaniment  of  lobar  ])neiunonia. 

Cardiac  thrombosis  is  frequently  the  immediate  cause  of  death,  being  due, 
in  ])art  at  least,  to  the  extreme  weakness  of  the  degenerated  heart-muscles. 
Sudden  cardiac  failure  is  quite  often  seen,  cases  dying  after  some  ai)]iarently 
trivial  exertion  necessitated  by  change  of  posture.  While  cardiac  thrombosis 
is  frequently  seen,  the  same  ])rocess  in  the  veins  is  observed  niuch  less  fre- 
quentlv  in  this  disease  than  in  typhoid  fever. 

P>rief  allusion  has  been  made  to  the  tendency  to  the  oeeiirrence  of  embolism 
in  various  organs.  Whatever  may  be  the  cause  of  this  liability,  its  fre(|iieney 
is  remarkable.  Almost  all  of  the  c-hief  organs  of  the  body  may  be  alVectcd, 
giving  rise  to  the  symptoms  peculiar  to  that  condition  when  occurring  in  other 
morbid  conditions.  8uj)erfi('ial  gangrene,  prol)ably  a  result  of  embolism,  has 
been  seen  in  the  extremities  and  alfecting  the  tip  oI'iIk'  mxc  and  ears. 

The  digestive  tract  is  not  especially  prone  to  offer  a  field  lor  cninplications 
in  this  disease.  Supjuu-ative  jianttitis  is  a  condition  tlial  may  oc<-nr.  as  in  one 
of  the  cases  occurring  in  the  e|)i(lcniic  olxcrvcd  by  llic  anther.  It  occurs  in  a 
varying  number  of  cases  in  different  cpidcrni<-s.  I  liccniinli  is  a  (Vc(|ncnt  and 
unfavorable  syni|)tom,  being  not  only  productive  of  inneli  discomfort,  but  also. 
exhaustin<'- strength  and   preventing  natural  rot.      I  laMiiali'iiicsis  is  imi  a  v<'ry 


158  RELAPSING    FEVER. 

rare  complication,  and  is  of  very  unfavorable  import,  three  out  of  four  cases  in 
which  it  occurred  in  our  series  of  cases  being  fatal. 

Altlipugh  diarrhoea  is  not  so  frequent  as  in  typhoid  fever,  it  occurs  in  a  con- 
siderable proportion  of  cases,  and  may  be  sufficiently  profuse  to  bring  about  a 
fatal  result.  Melfena  may  occur  to  a  varying  extent,  and  dysentery  was,  as 
might  be  expected,  a  notable  complication  in  some  of  the  epidemics  occurring 
in  India.  General  peritonitis  is  rarely  present  save  as  a  result  of  splenic  rup- 
ture :  when  present  a  fatal  result  may  be  predicted  with  certainty. 

Splenic  abscess  occurs  with  sufficient  frequency  to  cause  us  to  be  on  our 
guard  lest  it  may  be  the  lesion  present  in  those  cases  where  the  temjierature  of 
what  would  naturally  be  the  period  of  apyrexia  remains  above  normal.  Rup- 
ture of  a  sj)leuic  abscess  may  be  the  cause  of  a  generalized  purulent  perito- 
nitis. The  occurrence  and  significance  of  perisplenitis  has  already  been  men- 
tioned. 

The  urinary  system  is  the  seat  of  varying  morbid  conditions,  some  of  which 
are  of  great  importance  in  determining  the  result.  Albuminuria  is  present  in 
a  very  large  number  of  cases,  and  is  not  necessarily  a  cause  of  very  serious 
alarm.  When,  however,  the  excretion  of  albumin  is  accompanied  by  the  pres- 
ence of  tube-casts,  the  prognosis  is  very  grave.  The  affection  of  the  kidneys 
may  vary  from  simple  congestion  to  the  lighting  up  of  an  old  chronic  process 
or  tlie  production  of  an  actual  acute  nephritis,  which  may  be  hseraorrhagic  in 
character.  Complete  suppression  of  urine  is  at  times  present.  Hsematuria 
may  be  profuse  and  exhausting :  it  is  a  grave  complication,  and  is  often  fol- 
lowed by  a  fatal  issue.  Glycosuria  has  been  observed  during  the  course  of 
some  cases. 

Profuse  haemorrhage  from  the  uterus  may  occur,  and  it  is  recorded  that  in 
one  case  observed  by  Wolberg  the  menstrual  accession  seemed  to  be  brought 
on  by  the  general  disease.  Abortion  usually  happens  when  the  disease  attacks 
pregnant  females. 

Purulent  otitis  media  or  purulent  rhinitis  may  present  itself  during  some 
part  of  the  course  of  the  disease. 

Various  local  palsies  occur  with  peculiar  frequency  during  or  after  attacks 
of  relapsing  fever.  The  lower  extremities,  shoulders,  arms,  or  forearms  may 
be  affected.  Precisely  what  condition  is  the  underlying  cause  of  these  palsies 
it  is  sometimes  difficult  to  determine;  but  in  most  cases,  and  more  certainly 
in  those  with  coincident  anaesthesia,  a  perineuritis  may  be  assumed  as  the 
pathological   lesion. 

An  extremely  frequent  complication  is  collapse.  This  may  be  due  to  car- 
diac weakness  from  degeneration  of  the  heart-muscle,  to  cardiac  thrombosis, 
to  rupture  of  the  spleen,  or  to  internal  or  external  haemorrhage.  All  of  these 
conditions  have  been  more  particularly  mentioned  above. 

Following  an  attack  we  may  have  a  variety  of  more  or  less  important 
pathological  conditions.  A  frequent  sequel  is  intense  and  persistent  cephalal- 
gia, or  severe  rheumatoid  pains  with  or  without  swelling  of  the  joints  may 
persist.     In  some  cases  imbecility  has  been  known  to  follow  upon  an  attack 


BIAGXOSIS.  159 

of  this  disease.     Intense  anseniia  is  by  no  moans  a  rare  seciuel,   while  dia- 
betes mellitus  and  aeute  miliary  tuberculosis  are  aniono-  the  rarer  results. 

A  frequent  sequel  is  a  peculiar  ophthalmia  that  is  subdued  with  difHculty 
and  is  of  long  duration.  Tiiis  is  most  frequently  seen  in  indivitluals  whose 
nutrition  was  impaired  before  their  attack  of  rela})sing  fever.  Optic  neuritis 
and  atrophy  are  among  the  rarer  sequelae. 

Diagnosis. — It  would  seem  at  first  sight  that  the  existence  of  the  specific 
spirillum  in  the  blood  would  be  sufficient  to  prevent  all  chance  of  confounding 
this  with  any  other  disease.  This  would  be  true  were  it  possible  or  customary 
to  examine  the  blood  of  every  patient,  and  were  it  always  an  easy  matter  to 
discover  this  organism  when  such  an  examination  was  made.  In  the  earlier 
cases  of  an  epidemic  that  is  so  rare  a  visitant  to  any  one  locality  as  is  the  one 
now  under  consideration  it  is  not  probable  that  a  correct  diagnosis  will  be 
made  until  either  a  case  has  been  observed  that  has  gone  through  a  relapse  or 
a  clear  case  of  contagion  has  been  remarked. 

To  enumerate  again  the  prominent  symptoms  :  a  sudden  onset  with  cliill, 
preceded  by  few  or  no  prodromes;  enlargement  of  liver  and  spleen  ;  a  flushed 
face ;  rapid,  bounding  pulse ;  rapid  rise  of  temperature  without  marked  ner- 
vous disturbance;  intense  rheumatoid  pains;  cephalalgia  and  obstinate  insom- 
nia; tingling  of  the  extremities ;  tenderness  and  pain  in  the  epigastric  and 
livpochondriac  regions  ;  nausea  and  vomiting  ;  haemorrhages  from  various  sur- 
faces ;  frequent  jaundice ;  crisis,  followed  by  a  period  of  normal  or  subnor- 
mal temperature.  These  go  to  make  up  a  picture  too  characteristic  to  be  mis- 
taken where  we  are  induced  to  bear  in  mind  the  existence  of  this  affection. 

The  diseases  with  which  it  is  most  apt  to  be  confounded  are  ty])hus 
fever,  typhoid  fever,  malaria,  and  rheumatic  fever. 

In  tvphus  the  onset,  although  quite  abrupt,  is  usually  much  less  so  than 
in  relapsing  fever.  The  temperature  rises  less  suddenly,  but,  instead  of  the 
insomnia,  persistent  headache,  rheumatoid  jiains,  and  freedom  from  the  cere- 
bral svmptoms  of  liyperpyrexia  which  mark  relai)sing  fever,  there  appear 
delirium,  deepening  stupor,  subsultus,  and  rapid  loss  of  cardiac  power.  To 
these  must  be  added  the  appearance  of  the  characteristic  eruption  on  the  fourth 
day  and  the  absence  of  the  spirillum  from  the  blood. 

In  typhoid  fever  we  have  gradual  and  progressive  rise  of  temperature,  with 
early  epistaxis,  diarrhcea,  increasing  muscular  weakness,  tendency  to  hebetude, 
tympanv,  local  tenderness  in  the  right  iliac  fossa,  and  u|)()n  the  seventh  or 
eighth  day  the  characteristic  erui)tion. 

To  distinguish  relapsing  fever  from  malarial  i)ois(.niug  is  less  dilVK  nil  if 
we  bear  in  mind  the  place  of  residence  or  l)nsiness,  and  note  the  iircscnce 
or  absence  of  periodicity,  the  j)resence  in  the  blood  ol'  pccidiar  organisms  in 
each  disease,  and,  finally,  the  ready  control  of  (he  malarial  manifi-stations  by 
quinine.  From  yellow  lever  the  history  of  the  case  as  to  residence  would  !.<•, 
as  a  rule,  sufficient  to  prevent  error. 

In  rheumatic  fever  without  arthritis  we  may  have  r:ipi<l  rise  of  tempera- 
ture with  tendenev  to  hvperpvrexia,  and  severe  dilliise  |)ains  closely  liKe  those 


160  RELAPSING    FEVER. 

noted  in  relapsing  fever  ;  but  the  acid  sweats,  the  frequent  cardiac  complica- 
tions, the  absence  of  marked  eidargement  of  the  spleen  and  liver,  of  jaundice, 
and  of  the  spirillum  in  the  blood  will  establish  the  diagnosis.  In  no  disease 
is  hyperpyrexia  more  surely  attended  with  grave  cerebral  symptoms  than  in 
rheumatism  ;•  and  this  and  the  absence  of  any  critical  fall  in  the  temperature 
are  further  points  of  distinction. 

Prog-nosis. — Although  this  disease  presents  such  alarming  symptoms,  and 
in  spite  of  the  large  number  of  complications  that  may  occur,  the  prognosis 
is  usuallv  favorable.  The  sudden  and  extreme  elevation  of  temperature,  with 
the  intense  muscular  pains,  furnishes  a  picture  that  would  seem  to  point  to 
a  disease  of  much  greater  mortality  than  the  one  under  consideration.  The 
actual  mortality  varies  much  in  different  epidemics,  being  chiefly  governed 
bv  the  proportion  of  the  bilious  typhoid  form  as  compared  with  the  ordi- 
nary and  uncomplicated  variety.  The  death-rate  varies  from  2  or  3  to  even 
50  per  cent. 

The  more  unfavorable  symptoms  are — prolonged  pyrexia  after  the  pyretic 
period  should  have  been  completed  ;  pneumonia  or  intense  pulmonary  conges- 
tion ;  active  maniacal  or  muttering  delirium  ;  the  typhoid  state ;  convulsions, 
with  or  without  albuminuria,  nephritis,  and  hsematuria. 

Treatment. — The  special  points  for  consideration  in  regard  to  the  treat- 
ment of  this  disease  are  the  prevention  of  contagion,  the  reduction  of  hyper- 
pyrexia, the  combating  of  the  pain,  insomnia,  asthenia,  and  various  complica- 
tions, and  the  prevention  of  the  relapse. 

In  regard  to  prophylaxis  but  little  need  be  said,  as,  aside  from  actual  con- 
tact of  the  person  with  one  ill  of  the  disease  or  with  his  emanations,  the  pre- 
disposing causes  are  such  as  are  decidedly  unhygienic  from  a  general  as  well 
as  from  a  special  point  of  view.  The  fact  that  the  disease  may  be  carried  by 
fomites  should,  however,  be  constantly  borne  in  mind,  and  all  our  efforts  should 
be  directed  toward  lessening  the  risk  so  produced  to  as  great  an  extent  as  in 
our  power. 

The  patient  should  be  isolated,  and  all  clothing,  whether  of  body  or  bed, 
should  be  promptly  burnt  or  plunged  into  boiling  water  or  strong  bichloride- 
of- mercury  solution  immediately  after  havino;  been  discarded,  and  before  it  has 
been  handled  by  more  people  than  are  actually  necessary.  During  the  time 
of  an  epidemic  such  hotbeds  of  contagion  as  are  plentiful  in  the  slums  of  all 
large  cities  should  be  dealt  with  as  radically  and  thoroughly  as  possible. 

Absolute  confinement  in  bed  and  avoidance  of  exertion  are  essential  ele- 
ments of  treatment,  and  should  be  insisted  on  not  only  during  the  febrile  stage, 
but  during  the  intermission  as  well.  The  diet  must  consist  of  liquids,  such  as 
milk,  koumyss,  pancreatized  milk,  broths,  etc. 

It  must  be  admitted  that  we  have  no  specific  remedy  for  this  disease,  and 
that  it  is  at  present  beyond  our  power  either  to  check  the  growth  of,  or  to 
destroy,  the  specific  parasite  that  is  its  apparent  cause.  Not  only  has  quinine 
no  specific  influence  in  controlling  the  manifestations  of  this  disease,  such  as  it 
exerts  over  the  periodic  symptoms  of  malaria,  but  it  fails  even  to  markedly 


TREATMENT.  161 

affect  the  pyrexia,  while  in  some  cases  it  adds  to  the  discomfort  in  the  head 
and  may  also  excite  or  increase  gastric  disturbance.  It  is  tiieret'ore  to  be  used 
carefully  if  at  all,  and  never  in  the  large  doses  that  have  been  triwl  in  times  past. 

Tiie  other  great  antiperiodic  drug,  arsenic,  seems  to  iuive  no  more  control- 
ling influence  than  has  quinine.  Tiie  use  of  oil  of  eucalyptus  or  eucalyptol  has 
not,  to  my  knowledge,  been  tried.  All  efforts  to  avert  or  postpone  the  occur- 
rence of  the  relapses  have  hitherto  proved  incilcctiial. 

The  most  important  indication  of  reduction  of  the  high  temperature  should 
undoubtedly  be  met  promptly  by  hydrotherapy.  No  adequate  reports  are  yet 
at  hand  to  sliow  the  effect  of  the  systematic  use  of  cold  baths  in  iclieving  the 
symptoms  and  modifyin^r  the  cause  of  this  disease.  But  in  spite  of  the 
remarkable  tolerance  of  the  high  temperature,  there  is  every  reason  t(.  hope 
that  its  prompt  reduction  may  prove  the  most  satisfactory  and  effective  method 
of  treatment  in  this  curious  affection. 

Antipyrine,  antifebrin,  and  thallin  were  used  in  the  late  Russian  epidemic, 
but,  according  to  the  reported  observations,  were  without  benefit,  and  even 
produced  such  great  prostration  or  nausea  and  vomiting  that  their  use  had  to 
be  discontinued. 

For  the  rheumatoid  pains  and  insomnia  morphine; or  other  opiate  will  give 
the  greatest  relief,  while  its  sedative  action  upon  the  gastro-intestinal  tract  is  a 
further  advantage.  Hypodermic  injections  of  morphine  and  atropine,  combined 
with  the  free  use  externallv  of  anodvne  liniments,  will  be  found  of  yreat  value. 
Salicin,  salicylic  acid,  and  salicylate  of  sodium  have  been  fullv  tried,  but  have 
not  been  found  to  exert  any  good  influence  upon  the  rheumatoid  j)ains. 

In  a  disease  such  as  this,  where  asthenia  is  nuich  to  be  dreaded,  all  depress- 
ing remedies  must  be  carefully  avoided.  For  this  reason,  and  also  because  of 
the  tendency  to  gastric  disturbance,  chloral  and  the  bromides  must  be  tried 
with  great  caution.  In  the  above-mentioned  epidemic  in  Philadelphia  but  little 
or  no  benefit  was  obtained  from  these  drugs  as  nervous  sedatives  and  hypnotic^s. 

Aside  from  care  in  diet,  the  gastric  irritability  may  re()uire  the  use  of  .some 
more  direct  medication,  as  by  small  doses  of  calomel,  sid)uitrate  of  bisnuith,  or 
nitrate  of  silver. 

Stimulants  in  the  form  of  whiskey  or  brandy  are  re(|iiii'e(l  in  aluiost  every 
case,  and  should  be  freclv  given  in  accordance  with  (lie  ;uii<iiiii(  n|' pi-ostration. 
Ammonia,  digitalis,  com])()und  spii'it  of  ethei',  or  strychnine  :n;iy  be  \i:^vi\  as 
adjuvants  to  the  alcoholic  stimulants. 

As  the  jaundice  is  in  large  part  of  hremic  origin,  no  sjteeial  treatment  ean 
i)e  advised,  but  the  condition  of  the  stomach  and  duodeium)  nuist  be  consid- 
ered and  carefully  treated.  The  hiccough  may  I)e  eitiiei-  relieved  or  cheeked 
l)y  the  administration  of  chloroform,  this  drug  also  controlling  the  |teeuliar 
])eriodical  chills  that  occur  in  some  ea<es.  In  obstinate  eases  liy|)odenui<! 
injections  of  morphine  and  atroi)ine  into  the  (issues  around  (he  base  of  the 
chest  may   be  tried. 

Complications  nni>(  be  met  as  they  arise,  bnt  during  (lie  whole  e<iiir>e  oC 
treatment  the  need  for  support  of  the  vital  forces  nni.st  ever  be  kejW  in  mind. 

Vol.  L— II 


CEREBRO-SPmAL  FEVER. 

By  WILLIAM   PEPPER. 


Definition. — Cerebro-spinal  fever  is  a  specific,  infectious,  pandemic  disease, 
slightly  if  at  all  contagious,  probably  niicrobic  in  origin,  occurring  sporadi- 
cally or  in  epidemics,  characterized  anatomically  by  inflammation  of  the 
meninges  of  the  brain  and  spinal  cord,  and  clinically  by  irregular  nervous 
symptoms  pointing  to  profound  disturbance  of  the  cerebro-spinal  functions,  the 
most  prominent  of  which  are  intense  pain  in  the  head  and  often  in  the  trunk 
and  extremities,  hyperaesthesia,  contraction  of  the  muscles  of  the  nucha  and 
back,  vomiting,  irregular  fever,  delirium,  and,  in  severe  cases,  coma. 

Name  and  Synonynas. — No  satisfactory  title  has  yet  been  suggested  for 
this  disease.  Upon  the  whole,  cerebro-spinal  fever  seems  preferable.  It  is 
open  to  the  objection  of  implying  that  the  fever  is  dependent  upon  the  menin- 
geal lesions,  whereas  it  is  an  infectious  disorder  of  the  general  system,  and  the 
meningitis  is  only  one  of  its  manifestations.  For  the  same  reason  we  refuse  to 
accept  the  name  "  enteric  fever  "  in  place  of  typhoid  fever.  But,  in  the  lirst 
place,  although  the  intestinal  lesions  in  typhoid  fever  are  of  great  importance, 
they  do  not  dominate  the  symptomatology  of  that  disease  nearly  to  the  same 
extent  as  does  the  cerebro-spinal  meningitis  the  symptoms  and  course  of  the 
disease  we  are  now  considering.  Further,  it  cannot  be  said  that  any  of  the 
clinical  conditions  in  cerebro-spinal  fever  suggest  for  it  a  descriptive  name  so 
characteristic  as,  for  instance,  typhoid  is  of  the  fever  which  is  almost  univer- 
sally known  by  this  term.  Again,  there  are  weighty  objections  against  all 
other  names  suggested.  The  disease  is  so  often  sporadic  that  I  fear  the  term 
"  epidemic  cerebro-spinal  meningitis"  has  not  rarely  led  to  a  failure  to  recognize 
the  nature  of  isolated  cases.  "  Infectious  cerebro-spinal  meningitis  "  is  a  name 
I  have  thought  of  proposing,  and  it  may  have  some  advantages,  but  it  does  not 
mention  the  acute  febrile  nature  of  the  disease,  and  it  must  be  remembered 
that  there  are  other  forms  of  acute  infectious  meningitis.  Other  names  which 
have  been  more  or  less  widely  used,  such  as  spotted  fever,  petechial  fever, 
malignant  purpuric  fever,  have  become  wholly  obsolete.  Pending  the  sugges- 
tion of  a  better  name,  it  seems  desirable  to  unite  in  the  use  of  the  title  "  cerebro- 
spinal fever,"  since  the  possession  of  a  simple,  clear,  generally-accepted  name 
certainly  favors  the  clinical  recognition  of  a  disease  and  an  appreciation  of  its 
nature. 

History. — There  .seems  to  be  no  reason  to  believe  that  the  disease  was  clear- 
ly recrognized  before  the  early  part  of  the  present  century.     Whether  or  not  it 

162 


.J  I 


HISTORY 


163 


existed  before  cannot  now  be  dcterminecl,  altliough  some  autliors  claim  that  there 
is  evidence  of  its  having  occurred  even  in  ancient  times.  It  seems  difficult  to 
doubt  its  occasional  occurrence,  as  the  specific  cause  has  probably  not  come  into 
existence  of  recent  years  only.  Yiesseux  in  1805  appears  to  have  been  the  first 
to  give  a  clear  description  of  an  epidemic  which  occurred  in  Geneva,  and  in 
which  33  persons  died.  In  the  following  year  the  disease  made  its  appearance 
at  Medfield,  Mass.  From  this  date  up  to  1816  local  epidemics  were  observed  in 
various  countries  of  Europe  and  in  several  parts  of  the  United  States.  It  then 
disappeared  entirely  until  1822-23,  when  cases  were  reported  from  Vesoul, 
France,  and  from  ]Middletown,  Conn.,  and  after  this,  up  to  1837,  from  a  few 
other  localities.  From  1837  the  disease  began  to  si)read  throughout  France, 
and  for  years  prevailed  extensively  there.  Since  that  date,  also,  epidemics  have 
appeared  suddenly,  and  often  simultaneously,  in  different  parts  of  the  world 
widely  separated  from  each  other,  and  where  there  has  not  been  the  slightest 
possibility  of  transportation.  They  lasted  a  variable  time  and  were  more  or 
less  widely  spread.  Sometimes  the  disease  was  for  years  unheard  of  in  one 
country  while  prevailing  in  another.  From  1850  to  1854  it  was  unheard  of 
anywhere.  Since  1860  epidemics  have  occurred  in  nearly  every  civilized 
country. 

In  the  United  States  it  has  at  times  been  very  prevalent  and  very  fatal. 
In  1864,  400  persons,  out  of  a  population  of  6000,  died  of  it  at  Carbondale, 
Pa.  It  affected  both  the  Uni(m  and  .Confederate  armies  during  the  Civil 
War,  and  was  at  times  very  malignant.  Although  782  deaths  from  cerebro- 
spinal fever  were  reported  in  New  York  City  in  1872,  the  disease  appears  on 
the  whole  to  have  been  more  limited  there,  both  in  extent  and  duration,  than 
in  Philadelphia,  where  it  has  been  endemic  since  1863,  and  at  times  severe. 
The  tabular  statement  of  the  number  of  deaths  in  Philadelphia  yearly  from 
1863  to  1883,  published  by  Stille,  I  have  completed  up  to  the  year  1892  : 


Deaths  in  Philadelphia  from  Cerebrospinal  3Icniiigitis  from  I860  to  1891, 

inclusive. 


18fi3 
1864 
1865 
1866 
1867 
1868 
1869 
1870 
1871 
1872 


49 

384 

192 

92 

109 

55 

37 

36 

49 

133 


1873 
1874 
1875 
1876 
1877 
1878 
1879 
1880 
1881 
1882 


246 
82 
83 
85 
56 
90 
62 
78 
90 
51 


1883 
1884 
1885 
1886 
1887 
1888 
1889 
1890 
1891 


Total, 


50 
124 
87 
75 
45 
50 
37 
25 
23 
^575 


I  had  the  opportunity  of  studying  the  severe  lMiiladel|.lii:i  epidemie  d" 
1863-65  under  my  father,  the  late  Dr.  William  Pepper,  and  the  late  Dr. 
William  (k-rhard.  ^  I  made  a  iniml)er  of  autopsies  und<'i-  their  dire<-ti.in  and 
verified  the  nature  of  the  cases.  Having  been  Cainiliar  thus  .Mrly  with  the 
disease,  I  can  confirm  from  subsequent  experience  the  truth  of  Dr.  S(illC''s  stati*- 


164  CEBEBRO-SPIXAL    FEVER. 

ment,  that  it  has  lingered  in  this  locality  longer  than  has  been  reported  of  any 
other  place  in  this  conntry  from  which  information  has  been  obtained. 

Etiologry. — Of  the  predisposing  causes,  climate  seems  to  have  a  decided 
influence,  for,  although  cerebro-spinal  fever  has  occurred  in  all  portions  of  the 
temperate  zone,  it  is  unknown  in  the  tropics.  It  is  most  prevalent  in  the 
northern  regions  of  the  temperate  zone.  Season,  too,  is  an  important  factor, 
as  the  prevalence  of  the  affection  is  much  greater  in  cold  weather.  Not  only 
do  by  far  the  greater  number  of  epidemics  occur  in  the  winter-time,  but  those 
developing  then  are  more  severe  and  extended.  The  nature  of  the  locality  with 
regard  to  moisture,  elevation,  sea,  mountain,  city  or  country,  is  generally  con- 
sidered to  be  without  predisposing  influence.  With  regard  to  moisture, 
however,  this  opinion  is  not  undisputed.  Wollf,  who  carefully  analyzed  132 
cases  which  had  been  treated  in  the  Hamburg  hospital,  came  to  the  conclusion 
that  moisture  of  the  earth  and  air  is  a  decidedly  predisposing  factor.  Very 
few  of  his  cases  occurred  during  July  and  August,  the  dry  months  of  the 
year.  As  in  regard  to  all  infectious  diseases,  it  may  be  said  that  bad  hygienic 
conditions,  as  exposure,  overcrowding,  excessive  bodily  or  mental  exertion, 
insufficient  food,  and  the  like,  exercise  a  predisposing  influence.  But  it 
appears  that  the  effect  of  these  conditions  is  much  less  marked  as  regards  the 
occurrence  of  cerebro-spinal  fever  than  of  other  diseases  of  this  class.  I  must 
state,  however,  that  in  the  majority  of  the  cases  I  have  seen  there  has  been 
some  marked  defect  in  the  sanitary  condition  of  the  dwelling  or  in  the  physi- 
cal condition  of  the  individual.  In  the  other  cases  iiealthy  subjects  under 
admirable  sanitary  conditions  were  attacked  violently.  It  has  often  been 
noticed  that  soldiers  crowded  in  barracks  and  the  occupants  of  tenement- 
houses  suffer  most  severely.  On  the  other  hand,  in  some  epidemics  large 
cities,  which  apparently  afforded  the  most  favorable  conditions  for  severe 
attacks,  escaped  entirely,  and  tiie  disease  has  devastated  cleanly  villages  or 
occurred  in  isolated  outbreaks.  Race  is  not  a  predisposing  factor.  Sex  is 
also  probably  without  influence,  and  that  more  males  than  females  are  attacked 
is  doubtless  due  to  the  fact  that  the  former  are  more  exposed  to  privation, 
crowding,  and  other  predisposing  causes.  Age  is  a  very  important  factor. 
Statisticians  agree  that  the  disease  is  far  more  prevalent  among  children,  and 
is  also  more  fatal  among  them.  J.  L.  Smith  found,  from  the  reports  of  the 
New  York  Board  of  Health,  that  infants  under  one  year  of  age  furnished  the 
largest  proportion  of  fatal  cases.  Different  epidemics  have,  however,  differed 
widely  as  to  the  relative  proportion  of  adults  and  children  attacked. 

The  question  whether  cerebro-spinal  fever  can  be  acfjuired  by  direct  contact 
with  or  proximity  to  a  patient  suffering  with  this  disease  is  an  important  one. 
It  is,  however,  almost  universally  admitted  -that  it  is  either  not  directly  con- 
tagious at  all  or  so  to  a  very  slight  extent.  Not  only  do  the  first  cases  of  epi- 
demics develop  without  there  existing  the  slightest  possibility  of  the  disease 
having  been  accpiired  by  contact  with  other  cases,  but  the  majority  of  cases 
occur  singly  in  fiimilies,  and  where  several  cases  do  occur  in  a  household  it  is 
never  possible  to  trace  any  fixed  period  of  incubation  between  them  which 


ETTOLOdY.  165 

might  indicate  tliat  they  had  ae(iuiml  the  disease  the  one  tVoni  the  other. 
Nurses  and  physicians  in  attenchuiee  are  attacked  with  the  greatest  rarity. 
Nor  does  the  evidence  justify  the  oi)inion  that  it  can  he  transmitted  by  the 
secretions.  On  the  otlier  hand,  there  is  abundant  ])roof  of  the  existence  of 
a  specific  poison  which  may  attach  to  certain  liouses  or  localities  so  as  to  render 
them  infectious.  An  imi)ressive  instance  is  rccorded  l)y  Ilirsch,  in  which  a 
woman  who  had  nursed  a  j)atient  with  cerebro-spinal  fever  leturned  to  her 
home  in  another  village,  and  there  sickened  and  died.  Mourners  at  the 
funeral  came  from  another  township,  and  three  of  these  died  from  the  disease 
soon  after.  ^Moreover,  there  are  cases  on  record  which  indicate  verv  strongly 
that  the  disease  may  be  contracted  by  contact  with  infected  garments,  if  n()t 
by  direct  contagion  in  rare  cases.  In  one  instance,  reported  by  J.  L.  Smitii,  a 
mother  was  attacked  by  cerebro-sjiinal  fever  two  days  after  washing  the  clothes 
worn  by  her  son,  wlio  had  died  with  it,  and  a  few  days  later  her  infant  also 
sickened  and  both  died.  One  of  the  most  remarkable  published  cases  with 
which  I  am  acquainted  is  that  reported  by  Kohlmann.  A  servant-girl  died 
with  typical  symptoms  of  cerebro-spinal  fever.  Her  clothes  were  lent  bv  her 
family  to  different  neighbors.  A  man  in  one  house,  who  had  received  a  coat, 
was  attacked  by  the  disease  some  montiis  later,  and  several  weeks  afterward 
his  son  was  stricken  down,  and  in  one  week  more  his  daui-hter.  A  woman 
who  had  visited  the  last  ease  for  not  more  than  ten  minutes,  and  wlio  had  held 
the  head  of  the  ])atient  while  the  throat  was  being  examined  by  the  physician, 
suffered  from  the  disease  in  a  mild  form  eight  days  later.  Another  coat  was 
lent  to  a  young  boy  in  another  house  in  a  different  part  of  the  citv.  He  took 
the  disease  and  died,  while  his  mother  also  died,  })rol)ably  of  the  same  affec- 
tion, although  it  began  in  her  case  as  a  croupous  pneumonia. 

Instances  such  as  these,  together  with  other  j)eculiarities  of  the  affection, 
warn  us  not  to  be  dogmatic  as  to  the  possibilities  of  the  transmission  i>f  the 
disease  when  the  poison  is  virulent  and  the  system  unusually  suscej)tible. 

Recognizing,  then,  the  existence  of  a  specific  virus  as  the  true  cause  of  this 
disease,  it  must  be  stated  that  its  exact  nature  is  as  yet  unknown.  It  is  generally 
believed  to  be  microbic.  A  micro-organism  identical  with  or  indistinguishable 
from  the  pneumococcus  has  repeatedly  been  found  in  the  meningeal  exudation. 
Manv  investitrators  claim  that  this  is  the  onlv  microbe  which  occiu's  in  the  men- 
inges  in  this  disease.  It  certainly  is  the  one  oftenest  discovered,  i)ut  in  many 
cases  other  oi'ganisms  as  well  have  been  described,  so  that  it  wouhl  seem  |>os- 
sible  that  the  disorder  may  be  capable  of  being  j)roduced  l)y  dillerent  species 
of  microi)es.  Foa  and  Uffreduzzi  made  some  interesting  studies  of  the  pneu- 
mococcus found  in  the  meninges  of  several  cases,  and  ol)scrved  that  it  re(aiue<l 
its  vitality  both  after  exposure  to  cold  and  alter  drying. 

The  inference  has  i)een  suggested  that  this  <iisease  may  be  caused  by  several 
different  species  of  micro-organisms,  of  which  lln'  laiicc->li:i|»ed  coccus,  similar 
to  or  identical  with  the  pneumococcus,  is  tlie  mo>t  coniiiiun  ;  luit  I  do  not 
consider  that  the  bacteriological  studies  .if  thi-  «|iie<tiou  are  snllicieiillx  ad- 
vanced  to  justify   this  opinion.      \Vhatev<r  the  exact   nature  ol'  tiie  specilic 


166  CEREBROSPINAL    FEVER. 

micro-organism,  assuming  its  existence,  it  evidently  is  of  widely  diffused 
occurrence,  and  probably  has  its  growth  favored  by  moderate  temperature  and 
by  moisture ;  when  scant  in  numbers  or  feeble  in  virulence  it  is  inoperative  or 
affects  only  susceptible  systems,  thus  producing  isolated  cases  of  the  disease ; 
whereas  when  local  and  atmospheric  conditions  favor  it  acquires  such  con- 
centrated intensity  as  to  act  uniformly  and  violently  upon  those  who  receive 
it  into  their  systems.  We  have  no  actual  knowledge  of  the  mode  in  which 
the  virus  gains  entrance  to  the  economy. 

Morbid  Anatomy. — Emaciation  is  very  great  in  the  bodies  of  those  who 
have  been  long  sick.  In  rapid  cases  no  such  change  is  exhibited  to  any  degree. 
Rigor  mortis  is  marked.  Decomposition  often  commences  early.  Ecchymoses 
usually  are  extensive.  The  remains  of  different  eruptions,  particularly  of 
petecliiiB  and  herpes,  are  often  found  on  the  skin.  Abscesses  are  sometimes 
met  with  in  the  subcutaneous  connective  tissue.  The  muscles,  especially  those 
along  the  vertebral  column,  are  dry  and  dark  reddish-brown  or  sometimes 
pale.  They  often  exhibit  a  waxy  degeneration  or  an  extensive  fatty  degenera- 
tion in  the  form  of  fine  granules.  Abscesses  are  at  times  seen  in  the  inter- 
muscular connective  tissue.     The  articulations  sometimes  contain  sero-pus. 

The  heart  is  often  flabby,  and  the  muscle-substance  exhibits  the  same  con- 
dition as  do  the  voluntary  muscles.  The  pericardium  is  sometimes  inflamed 
and  shows  ecchymoses.  Endocarditis  is  rare.  The  blood  is  usually  of  a  dark 
color  and  fluid,  or  any  clots  present  are  dark  and  soft.  Bubbles  of  gas  are 
occasionally  found  in  the  blood  of  the  heart  and  arteries.  In  cases  where  fever 
has  not  been  high,  and  especially  in  the  early  stages  of  the  disease,  the  blood 
may  coagulate  readily,  and  firm  whitish  clots  may  be  found  in  the  heart  or 
vessels. 

The  lungs  often  exhibit  congestion,  oedema,  bronchitis,  atelectasis,  or  pneu- 
monia. Ecchymoses  or  evidences  of  purulent  inflammation  are  sometimes 
seen  on  the  pleura. 

The  condition  of  the  spleen  is  of  special  interest,  as  bearing  on  the  true 
nature  of  the  disease.  Its  size  seems  pro])ortionate  to  the  degree  and  duration 
of  the  pyrexia.  It  is  rarely  as  much  enlarged  as  is  common  in  typhus,  and 
in  cases  where  the  inflammatory  lesions  are  marked  the  spleen  may  yet  be 
small  and  merely  congested. 

The  liver  is  congested  ;  the  stomach  and  intestines  generally  show  no  change 
except  occasional  congestion.  Sometimes  the  lymphatic  tissue  of  the  intestine 
is  hypertro|)liicd  and  rarely  idcerated.  The  kidneys  are  usually  congested,  and 
may  exhibit  the  lesions  of  nephritis.  The  mucous  membrane  of  the  bladder 
may  be  ecchymosed. 

Naturally  the  most  striking  lesions  in  cerebro-spinal  fever  are  those  of  the 
nervous  system.  The  calvarium  is  very  hypersemic.  In  acute  cases  the  sinuses, 
arteries,  and  veins  of  the  brain  are  found  engorged.  The  meninges  are  exceed- 
ingly hypertemic,  generally  throughout.  Death  may  occur  before  the  lesions 
have  advanced  beyond  this  stage.  The  dura  often  shows  scattered  pnnctiform 
haemorrhages,  and  its  surface  is  dry,  hypersemic,  and  more  or  less  adherent  to 


SYMPTOMA  TOLOG  V.  1 67 

the  arachnoid.  The  arachnoid  itself  is  often  normal,  but  in  other  cases  it  is 
dense  and  cloudy,  especially  along  the  vessels  and  in  the  depressions.  Serum, 
or  rarely  pus,  sometimes  occupies  the  space  between  the  arachnoid  and  the  dura. 
In  cases  which  have  run  a  prolonged  course  a  serous,  fibrinous,  or  purulent  exu- 
date takes  place  within  the  meshes  of  the  pia.  This  infiltration  is  generallv 
widespread,  but  is  especially  well  marked  in  the  depressions.  It  mav  be 
limited  to  scattered  patches  or  follow  the  course  of  the  vessels.  Pus  is  par- 
ticularly liable  to  be  found  in  the  Sylvian  fissure,  at  the  optic  chiasm,  the 
anterior  surface  of  the  pons,  and  the  surface  of  the  cerebellum ;  but  the  con- 
vexity is  also  commonly  involved,  and  I  have  seen  the  entire  surface  bathed 
with  a  thick  layer  of  pus.  The  pia  is  often  so  adherent  to  the  brain  in  places 
that  it  cannot  be  separated  without  tearing  the  latter.  The  brain-substance  in 
section  exhibits  xmmerous  punda  imsculosa.  Areas  of  softening  are  sometimes 
seen,  and  occasionally  the  whole  brain  is  softened.  Abscess  has  been  reported. 
Rarely  the  brain  is  oedematous.  The  choroid  })lexus  is  congested  and  inlil- 
trated.  '^I'he  walls  of  the  ventricles  are  softened.  In  long-standing  cases  the 
effusion  into  the  ventricles  of  serous,  turbid,  or  even  purulent  fluid  may 
become  very  extensive,  and  flattening  of  the  convolutions  with  atr()j)hy  of 
the  brain-substance  may  result  from  the  pressure.  Sometimes  chronic  hydro- 
cephalus ensues. 

The  condition  of  the  spinal  membranes  is  analogous  to  that  of  those  of  the 
brain.  The  dura  is  often  dark  and  hypera?mic,  and  extra vasated  blood  some- 
times separates  it  from  the  vertebral  canal.  The  arachnoid  is  often  cloudy  and 
infiltrated,  and  serum  or  pus  may  distend  its  cavity.  The  pia  is  hypera?mic, 
thickened,  and  adherent  to  the  cord,  and  a  serous,  fibrinous,  or  purulent  exu- 
date occupies  its  meshes.  This  exudation  may  be  almost  universal,  but  is  far 
more  commonly  situated  chiefly  at  the  posterior  aspect  of  the  cord.  The  cord 
itself  is  hyperpemic,  infiltrated  with  serum,  and  sometimes  softened.  Fron- 
miiller  reports  a  case  in  which  the  central  canal  was  dilated  and  filled  with  pus. 

The  organs  of  special  sense  may  exhibit  lesions.  Choroiditis  with  detachment 
of  the  retina  has  been  rejiorted.  Ulceration  of  the  cornea  soiuetimes  occurs. 
Purulent    inflammation    of    the    labyrinth    and    tympanic    cavity    has    been 

observed. 

As  might  be  expected,  both  cranial  and  special  nerves  are  (.ftcii  involved  in 
the  morbid  process.  The  auditory  and  optic  nerves  are  especially  liable  to 
suffer.  The  exudation  extends  along  their  lymi)h-sheaths,  and  the  roots  of 
the  special  nerves  are  often  bathed  in  pus.  Not  only  does  this  occur,  but  it  is 
not  infrequent  for  perineuritis  or  neuritis  to  spread  along  the  nerve-triud<s, 
leading  to  troublesome  sequels  or  even  grave  lesions  of  niiliition  in  the  i)arts 
to  which  they  are  distributed. 

Symptomatology.— The  symptoms  of  cerebro-spinal  fever  vary  so  greatly 
in  dilferent  epidemics,  and  even  in  dilfcrent  .-ases  in  the  same  epidemic,  that  it 
is  exceedingly  diffictdt  to  present  a  general  dcscripli-.n  ..I'  ihcm.  Nnmcn.iis 
and  elaborate  classifications  of  the  forms  of  the  disease  hav<'  b.-en  ma<l.-,  biK  to 
repeat  them  at  length  would  only  add  to  the  confusion  nlnady  existing.     The 


]68  CEREBROSPINAL    FEVER. 

simpler  the  elassificatioii  the  better,  and  the  following  seems  to  me  both  natural 
and  convenient  for  purposes  of  study  : 

1.  The  Ordinary  Form. — The  period  of  incubation  is  entirely  unknown. 
Prodromata  are  not  encountered  with  any  regularity,  and  when  present  last 
a  few  hours  to  a  few  days,  and  consist  of  depression,  loss  of  appetite,  head- 
ache, vertigo,  i)ain  in  the  back,  and  other  symptoms  of  an  entirely  indef- 
inite nature.  Ziemssen  states  that  there  is  sometimes  an  interval  of  several 
hours,  just  before  the  onset  of  the  disease,  in  which  all  prodromes  disappear. 
In  the  great  majority  of  cases  prodromes  are  absent,  and  the  disease  is  ushered 
in  with  great  suddenness  and  severity,  quite  distinct  from  the  beginning  of  an 
ordinary  meningitis.  The  attack  nearly  always  begins  between  noon  and 
midnight.  There  is  a  chill,  often  violent,  with  intense  headache,  repeated 
vomiting,  moderate  fever,  and  generally  a  strong,  full  pulse.  The  face  is 
usually  pale  and  livid,  and  denotes  great  suffering.  In  children  the  attack 
sometimes  begins  with  convulsions.  In  a  recent  sporadic  case  in  a  boy  of 
thirteen  years  the  attack  began  with  intense  pain  in  the  epigastrium,  with 
threatened  collapse. 

In  a  very  short  time,  generally  by  the  second  day  in  the  majority  of  cases, 
]>ain  and  stiffness  of  the  muscles  of  the  back  of  the  neck  develop,  and  consti- 
tute one  of  the  most  characteristic  symptoms.  The  headache  grows  worse  and 
there  is  sensitiveness  to  light  and  noise,  and  often  irritability  and  restlessness. 
The  ])ain  and  stiffness  extend  along  the  muscles  of  the  sj)ine,  and  even  into  the 
limbs  as  well,  where  the  suffering  may  be  very  intense.  In  severe  cases  retrac- 
tion of  the  head  and  orthotonos,  or  even  opisthotonos,  soon  develop.  As  a 
result  of  the  tonic  spasm  in  the  muscles  of  the  extremities,  the  forearms  are 
flexed  upon  the  arms  and  the  legs  upon  the  thighs.  There  may  be  tremor  or 
clonic  spasm  in  the  muscles  of  the  arms,  legs,  eyelids,  or  face.  Strabismus  is 
frequent.  The  pupils  are  dilated,  contracted,  or  unequal,  or  do  not  react  well 
to  light.  General  epileptiform  convulsions  with  unconsciousness  are  sometimes 
observed,  but  more  often  in  children  than  in  adults.  Local  paralyses  occa- 
sionally occur  in  various  })arts,  as  in  the  muscles  of  the  face,  of  the  eye,  or  in 
a  single  group  of  muscles  of  an  extremity  or  of  the  trunk. 

With  these  motor  symptoms  are  seen  also  disturbances  of  sensation.  The 
intense  pain  has  already  been  mentioned.  There  may  be  great  sensitiveness 
over  the  spine,  and  a  remarkable  hyperaesthesia  of  the  entire  surface  of  the 
body  and  of  the  joints.  Vertigo  sometimes  persists,  and  is  distressing  even 
when  the  patient  is  lying  quietly  in  bed.  Ringing  in  the  ears,  with  great  sen- 
sitiveness to  sound,  is  succeeded  by  deafness.  Photophobia  is  almost  constantly 
present,  and  there  may  be  double  vision  and  even  temporary  blindness.  Delir- 
ium occurs  very  early,  varying  from  a  simple  wandering  to  a  true  maniacal 
form,  and  often  alternating  with  stupor. 

The  tongue  is  coated  and  often  remains  moist,  though  in  severe  cases  it 
may  become  dry  and  brown.  Vomiting  usually  subsides  as  the  disease 
advances,  but  may  ])ersist  and  be  distressing.  Taste  and  appetite  are  lost.  The 
bowels  are  usually  constipated,  and  the  abdomen  may  be  decidedly  retracted. 


SYMPTOMA  TOLOG  V.  1 69 

The  amount  of  uriue  passed  is  variable,  but  is  apt  to  be  increased,  and  all)u- 
jnin  is  occasionally  present.  The  spleen  is  often  somewhat  enlarged,  as  already 
stated. 

Even  during  the  first  few  days  of  the  disease  the  skin  is  liable  to  exhibit 
eruptions.  Herpes  facialis  is  a  very  common  form,  and  a  petechial  rash  is 
quite  frequent.  Other  eruptions  likewise  occur  in  some  cases.  The  fever  is 
irregular  and  presents  no  typical  curve.  It  is  generally  moderate  in  degree, 
though  occasionally  it  is  high.  The  pulse  is  likewise  variable;  sometimes 
slow,  and  again  very  rapid.  Respiration,  too,  varies,  but  is  not  often  much 
accelerated.      Cheyne-Stokes  or  sighing  breathing  is  sometimes  encountered. 

The  disease  exhibits  a  variable  course,  but  generally  reaches  its  height 
between  the  third  and  the  sixth  day.  It  has  been  claimed  by  Frey  and  others 
that  a  remission  in  the  symptoms  sometimes  occurs  about  the  third  day, 
althou";h  it  lasts  but  a  short  time.  I  have  on  several  occasions  noted  this  in 
such  marked  degree  as  to  rouse  hope  that  error  in  diagnosis  had  been  made, 
but  the  characteristic  symptoms  quickly  resumed  their  course  of  development. 
The  duration  of  the  disease  may  be  from  a  few  hcMirs  to  several  months.  If 
the  case  tends  toward  recovery,  the  symptoms  become  less  marked  alter  five  or 
six  days,  the  spasms  grow  less,  the  mind  becomes  clearer,  and  the  depression, 
headache,  and  general  pain  ameliorate.  Convalescence  is  fairly  established  in 
one  or  two  weeks,  although  often  not  until  after  a  much  longer  time,  and  it  is 
verv  apt  to  be  interfered  with  by  complications  and  setiuclse. 

If,  on  the  contrary,  the  case  is  destined  to  cud  fatally,  the  symptoms  of 
nervous  excitement  pass  into  those  of  exhaustion  ;  delirium  changes  into  a 
state  of  coma  ;  prostration  grows  extreme,  the  jiulse  rajiid,  the  temperature 
hiirh,  and  there  is  paralysis  of  the  sphincters  with  involuntary  discharge  of 
urine  and  fteces.  Sometimes  the  course  of  fatal  as  of  non-fatal  cases  is  greatly 
prolonged,  lasting  weeks  or  even  months. 

•2.  The  Malignant  Form. — This  form  has  also  gone  under  the  title  of  ful- 
n)inant  {meningife  foudroyante,  meningitis  siderans),  a])oplectic,  rapid,  explo- 
sive, etc.  It  may  occur  sporadically  in  rare  instances,  and  with  variable  fre- 
quen(;v  in  all  epidemics,  but  especially  at  their  commencement.  The  patient, 
previouslv  in  perfect  health,  is  stricken  by  the  disease  with  the  greatest  sudden- 
ness, and  rapidly  passes  into  a  condition  of  collapse.  There  is  nsnally  a  vio- 
lent chill,  intense  headache  or  drowsiness,  great  prostration,  and  a  iivbic  pulse, 
which  mav  be  slow  at  first,  but  which  soon  grows  rai)id.  'lUvro  is  little  or  no 
iever— the  temperature  may,  indeed,  be  subnormal— and  there  may  be  coldness 
and  clamminess  of  the  skin,  with  cyanosis.  Respiration  is  slow  and  labored. 
The  urine  is  scanty  and  full  of  albumin.  Th.-rc  is  .•ontractioi.  of  the  muscles 
<.f  the  back  of  the  neck,  spasm  in  other  muscles,  or  <ven  general  einni.'  c.n- 
vulsions.  Delirium  aj.pears  almost  from  the  llrst,  and  rai)idly  jki^m-  into 
coma.     A   purpuric   rash   usually   <leveIops    and    often   .[uiekly   vesicates    or 

sloughs. 

These  cases  are  almost  invariably  fatal,  and  gen.Tally  so  within  a  few 
hours.      A  case  is  reporte.l  by  Cordon    in  whieh  death   oeeurn'd    in    five  honrs, 


170  CEREBROSPINAL    FEVER. 

and  in  the  Philadelphia  epidemic  of  1863  1  saw  cases  which  proved  fatal  in 
seven,  ten,  and  fourteen  hours,  respectively.  Rarely  the  fatal  ending  may  not 
take  place  until  the  third  day.  The  lightning-like  suddenness  of  the  onset  and 
the  malignancy  of  the  symptoms  surpass  any  description  which  can  be  given 
of  them.  If  reaction  is  established  and  the  case  is  prolonged,  as  happens  in 
rare  instances,  it  is  only  to  exhibit  a  course  of  long  duration,  with  great  vio- 
lence of  symptoms,  numerous  dangerous  complications,  and  ultimately  with 

crippling  sequels. 

3.  The  Mild  Form. — This  form  exhibits  throughout  symptoms  of  very 
little  severity.  Many  cases  scarcely  seem  to  need  confinement.  There  is  little 
more  than  severe  headache,  with  slight  vertigo  and  nausea,  while  fever. is 
absent  or  slight.  Occasionally  there  are  slight  stiffness  of  the  neck  and  vom- 
iting. In  a  few  days  the  patient  is  convalescent.  The  diagnosis  may  be  dif- 
ficult, except  when  the  case  occurs  during  epidemics  of  the  disease.  It  is  to 
be  borne  in  mind  that  all  the  symptoms  of  such  cases  may  suddenly  become 
very  severe. 

4.  The  Abortive  Form. — In  this  form  the  attack  begins  with  severe  symp- 
toms, which  last  only  two  or  three  days  and  then  suddenly  ameliorate.  It 
would  appear  that  in  these  cases  the  initial  constitutional  infection  is  marked, 
but  that  the  other  essential  constituent  of  the  disease,  the  meningeal  inflam- 
mation, is  present  in  very  light  measure. 

5.  TJie  Iniermittent  Fmiii. — This  is  another  well-recognized  variety  to 
which  reference  must  be  made.  In  it  there  occurs  daily  or  every  other 
day  a  decided  exacerbation  of  fever,  with  great  increase  in  the  severity  of  all 
the  symptoms,  these  exacerbations  being  separated  by  periods  of  almost  com- 
plete subsidence  of  all  the  manifestations  of  the  disease.  There  is,  iiowever, 
not  the  regularity  in  time  which  is  seen  in  malarial  fever,  and  the  temperature 
curve  resembles  rather  that  of  pyseraia.  The  intermissions  appear  either  at 
the  beginning  of  the  attack  or  toward  the  close.  Cases  of  this  form  are  apt 
to  be  prolonged. 

Of  the  remaining  forms  which  have  been  described  by  writers  may  be 
mentioned  the  nervous,  with  numerous  sub-varieties,  as  the  ataxic,  adynamic, 
cephalalgic,  neuralgic,  delirious,  etc.;  the  typhoid;  the  infiammatory ;  the 
chronic.  Nearly  all  of  these,  however,  find  their  places  naturally  among  the 
types  already  described,  and  consequently  need  no  further  mention  in  this 
connection.  Yet  it  is  necessary  to  be  aware  of  the  special  features  of  the 
chronic  form,  as  in  my  experience  it  has  usually  given  rise  to  embarrassment 
and  uncertainty  as  to  the  nature  of  the  disease,  as  it  runs  its  protracted  course 
to  a  fatal  issue  or  to  gradual  and  usually  partial  recovery.  Such  cases  are 
marked  l)y  continued  gastric  irritability  from  central  nervous  lesions;  pro- 
gressive extreme  emaciation,  until  the  patient  is  literally  a  living  skeleton  ; 
various  and  erratic  symptoms  of  perineuritis  and  of  subacute  meningitis,  and 
irregular  paroxysms  of  fever.  I  have  watched  the  course  of  such  symptoms 
for  ten  or  twelve  Aveeks,  and  cases  are  recorded  of  sixteen  weeks'  duration. 
Unquestionably,  there  is  central  disease  persisting  in  the  membranes  or  sub- 


DESCRIPTIOX   OF  IXDIVIDUAL    SYMPTOMS.  171 

stance  of  the  nervous  centres.  More  commonly  death  closes  the  scene,  but 
when  recovery  finally  ensues  the  patient  is  left  with  tlaiuagetl  special  senses, 
impaired  mind,  palsy  or  muscular  atrojihy,  and  persistent  nerve-])ains. 

Description   of  Individual   Symptoms. — Certain  of  tlu-   symptoms  of 
cerebro-spinal  fever  cleman<l  a  somewhat  more  extended  consideration. 

Chill  is  very  common  as  an  initial  symptom,  especially  in  atlults.  It  may 
vary  from  simple  chilliness  to  a  rigor  of  the  greatest  severity,  and  it  may  be 
repeated  several  times  on  the  first  day.  Prostration  is  an  early  and  prominent 
symptom,  and  is  conspicuous  throughout  the  whole  attack.  A  sense  of  faiut- 
ness  so  often  is  present  that  the  atfection  has  been  called  iyplms  syncopdlifi. 
Emaciation,  too,  takes  place  early,  and  in  severe  cases  is  rapid  and  great. 
The  emaciation  may  proceed  so  rapidly  that  it  would  a]ipear  to  be  due  to 
some  tropho-neurotic  disturbance.  Painful  swellings  of  the  joints,  resem- 
bling those  of  rheumatism,  but  sometimes  attended  with  purulent  effusion, 
were  first  described  by  James  Jackson,  Jr.,  and  have  since  been  repeatedly 
observed.  The  facial  expression  is  one  of  severe  pain.  The  features  are 
much  distorted,  or,  when  the  pain  is  persistent,  arc  fixed  and  rigid  and  the 
expression  is  dull.  At  the  outset  the  face  is  often  pale  and  sunken.  There 
is  not  the  sleepy  expression  of  typhoid  fever  nor  the  dusky  appearance  of 
typhus. 

Of  the  sensory  symptoms,  ])ain  in  the  head  is  one  of  the  earliest,  most  con- 
stant, and  most  distressing.  It  is  of  an  agonizing  nature,  except  in  the  mild- 
est cases  and  in  those  of  the  malignant  type.  In  tlje  latter  there  seems  to  ho 
no  time  for  headache  to  develop.  The  headache  is  subject  to  remissions  and 
exacerbations.  Its  situation  is  variable,  as  is  its  quality.  The  severity  of  the 
headache  seems  to  have  little  bearing  upon  prognosis,  although  its  cessation 
is  a  very  favorable  symptom.  Even  during  profound  unconsciousness  the 
patient  may  raise  his  hands  to  press  his  head  or  may  utter  cries  I'n.ni  time 
to  time.  Headache  may  persist  to  a  greater  or  less  extent  long  after  recov- 
ery from  other  symptoms. 

Pain  in  the  neck  and  back,  though  likewise  a  very  frequent  symi)tom,  is 
more  variable  than  headache  in  duration,  intensity,  and  extent.  In  soin(>  cases 
it  only  occurs  when  attempts  are  made  to  move  the  patient.  The  intensity  of 
the  pain  is  not  always  proportionate  to  the  degree  of  retraction,  provided  no 
effort  is  made  to  overcome  the  latter.  Pain  in  th(>  extremities,  especially  in 
the  legs,  is  also  a  common  symptom.  Movement  of  the  body  often  brings  it  .m 
or  intensifies  it.  It  shifts 'from  place  to  i)lace,  and  is  of  a  darting  charaetcr. 
Severe  darting  pain  frequently  attacks  other  parts.  In  the  abdomen  it  is  often 
situated  in  the  epigastric  and  umbilical  regions  or  is  acvompanicl  by  nbstiimtc 
vomiting,  and  in  the  chest  it  is  attended  by  .iiifwully  in  breathing.  In  a 
recent  sporadic  case  in  a  boy  aged  thirteen  years,  already  r.'l'.'rn.l  f:..  ih.'  atlaek 
began  with  intense  pain.  The  chihl,  who  was  out  playing  ball,  <anH-  Umuv  at 
noon  in  a  state  of  marked  collapse,  with  pale,  sunken  fi-atures  ;  vnv  w.ak,  small 
pulse;  stdmormal  temperature;  vomiting,  a.id  such  severe  epigastric  sulh-rM.g 
that  the  first  suppositi..n  was  that  Ur  hn.l  rrrnvcd  a  blow  th.-rr  .„•  tl,:,t  h-  ha.l 


172  CEREBROSPINAL    FEVEB. 

taken  some  irritant  poison.  Reaction  was  brought  abost  with  extreme  dif- 
ficulty. When  I  saw  him  in  consultation  on  the  second  day  the  diagnosis 
could  be  made  out,  and  the  case  ran  a  long,  desperate  course  to  a  final  linger- 
ing recovery.  Pain  often  begins  in  one  portion  of  the  body  and  darts  with 
lightning-like  rapidity  to  some  other,  perhaps  leaving  the  first  region  at  the 
same  time,  but  perhaps  also  continuing  there.  After  a  few  days  pain  usually 
betnns  to  grow  less,  and  by  the  end  of  the  second  week  is  much  less  marked. 

Widespread  hvpera^sthesia  of  the  skin,  and  afterward  of  the  soft  parts  and 
the  joints,  is  a  common  and  important  symptom,  though  by  no  means  always 
present.  It  seems  to  vary  with  the  epidemic.  It  is  oftenest  observed  in  the 
lower  extremities.  The  skin  may  be  so  painfully  sensitive  that  the  slightest 
touch  will  cause  an  outcry.  An  attempt  forcibly  to  open  the  eyelids  or  to 
straighten  the  neck  or  back  gives  })ain,  inde}>endently  of  that  in  the  muscles 
which  is  produced  by  this  action.  The  introduction  of  the  thermometer  into 
the  rectum  sometimes  evokes  an  outcry.  Hypersesthesia  is  one  of  the  early 
syuiptoms,  apjiearing  by  the  second  or  third  day.  It  is  often  associated  with 
great  sensitiveness  to  light,  sound,  and  odors.  Partial  aneesthesia  sometimes 
occurs,  but  is  not  frequent. 

Vertigo  is  often  j>resent,  and  may  develop  early  with  the  headache.  It 
may  be  one  of  the  prodromes,  and  be  so  severe  that  walking  is  nearly  impos- 
sible, and  patients  may  fall  and  be  unjjble  to  rise.  It  is  sometimes  present 
even  when  the  patient  is   reclining. 

The  mental  state  vari^.  Many  patients  seem  simply  apathetic.  Restless- 
ness is  of  common  occurrence  except  in  mild  cases  or  in  those  in  coma.  The 
severity  of  the  pain  causes  constant  tossing,  so  that  the  patient  may  move  all 
over  the  bed.  Sleeplessness,  too,  is  often  present,  and  is  sometimes  one  of  the 
prodromes.  But  little  genuine  sleep  is  obtained,  although  a  drowsiness  which 
borders  on  coma  is  common.  Delirium  is  a  very  frequent  symptom,  and 
exhibits  the  greatest  variety  both  in  degree  and  in  kind.  One  form  may  rap- 
idly change  into  another.  Though  sometimes  one  of  the  earliest  symptoms,  it 
nsually  does  not  develop  until  the  second  or  the  third  day.  Not  infrequently 
it  is  so  violent  that  restraint  is  demanded.  It  may  also  show  itself  as  a 
simple  delusion,  or  it  may  resemble  intoxication  or  hysteria.  It  is  seldom 
continuous  throughout  the  whole  attack,  but  is  liable  to  alternate  with  lucid 
intervals  or  with  somnolence.  Coma  eventually  follows  delirium  in  nearly  all 
fatal  cases,  but  usually  only  a  short  time  before  death.  Patients  may,  how- 
ever, exhibit  pronounced  coma  and  yet  recover. 

Of  motor  symptoms  the  most  characteristic,  and  one  rarely  absent,  is  con- 
traction of  the  muscles  of  the  nucha,  causing  retraction  of  the  head.  It  may 
appear  by  the  close  of  the  first  day,  but  far  more  often  not  until  the  end  of 
the  second  day.  When  once  developed  it  may  be  persistent,  lasting  even  into 
convalescence.  It  varies  in  intensity  from  a  slight  stiifness  to  a  retraction 
so  great  that  swallowing  is  difficult.  Hart  reports  a  case  in  which  a  slough 
in  the  tissues  of  the  back  was  ]iroduced  by  the  occn'put  jiressing  between  the 
scapulae.     In  a  large  number  of  cases  there  also  exists  a  tonic  contraction  of 


DESCRIPTIOX    OF   jyDIVIDlAL    SYMr'nUfS.  173 

the  erector  spinse  imiseles,  producing  gnulations  from  mere  stiifness  to  com- 
plete opisthotonos,  though  the  hitter  is  unusual.  It  renders  the  raising  of  the 
patient  in  bed  both  difficult  and  painful.  The  stiti'ness  lasts  several  weeks, 
even  sometimes  well  into  convalescence.  Rarely  the  muscles  upon  only  one 
side  of  the  spine  have  Uecn  contracted. 

Less  common  than  the  spasm  of  the  muscles  of  the  neck  and  back,  though 
still  quite  frequent,  is  that  of  those  of  the  abdomen  and  extremities.  The 
thighs  are  flexed  upon  the  abdomen,  the  legs  uj)on  the  thighs,  and  tlu-  fore- 
arms upon  the  arms.  Both  active  and  ])assive  movements  are  painful  and  dif- 
ficult of  execution.  Trismus  is  occasit)nally  seen,  and  is  a  most  unfavorable 
symptom. 

Clonic  spasm  of  the  muscles  is  less  freciucnt  than  the  tonic  contraction.  It 
is  oftenest  seen  in  voiuig  children.  It  mav  varv  in  dee-ree  from  twitchinu:  of 
certain  muscles  to  general  epileptiform  convulsions.  In  children  general  eon- 
vulsi(ins  sometimes  take  the  place  of  the  chill  in  ushering  in  the  disease,  but 
thev  may  exceptionally  constitute  the  first  symptom  in  adults  as  well.  Vio- 
lent convulsions  may  occur  repeatedly  during  several  days,  or  even  throughout 
the  disease,  and  yet  the  case  may  recover.  Or,  again,  they  do  not  occiu-  until 
late  in  the  disease,  and  are  then,  as  a  rule,  accompanied  Ity  a  decided  increase 
in  the  severity  of  all  the  symptoms.  Clonic  spasm  may  be  associated  with 
paralvsis  of  other  muscles  or  may  alternate  with  tonic  contraction.  Chorei- 
form movements  have  been  sometimes  observed.  Paralysis  is  one  of  the  less 
common  symptoms.  It  has  been  noticed  even  among  the  initial  synqitoms, 
but  this  is  very  rare,  and  it  is  generally  one  of  the  later  ones.  It  affects  most 
often  associated  groups  of  muscles,  as  those  of  deglutition  or  articulation,  or 
of  some  one  of  the  limbs,  or  it  may  develop  in  the  region  supplied  by  some 
one  of  the  cranial  nerves.  Hcmijilegia  and  even  general  |»aralysis  have  been 
reported,  but  are  rare.  Recovery  from  paralysis  usually  takes  place  as  con- 
valescence advances,  but  the  condition   may  be  more  or  or  less  iiermanent. 

Of  the  special  senses,  that  of  smell  is  not  often  affected,  as  far  as  can  be  deter- 
mined. Patients  are  sometimes  sensitive  to  odors,  and  J.  L.  Smith  reports  an 
instance  in  which  the  sense  was  tnitirely  lost  in  one  nostril.  Taste  appears  to 
be  no  more  affected  than  would  naturally  result  from  the  inllueiice  of  the 
fi'brile  state  upon  the  tongue  and  mouth.  The  eye  is  often  involved.  Intol- 
erance to  light  is  a  very  frequent  symptom.  The  condition  of  the  |»u|>ds  varies 
greatly.  Tliev  may  be  normal  or  dilated  or  contracted  cither  early  or  late,  or 
one  may  be  dilatcd'and  the  other  contracted.  Dilation  is  perhaps  more  com- 
mon than  contraction.  They  very  usually  «lo  not  react  well  to  light.  Stra- 
bismus, generally  convergent,  is  frequent,  and  may  develop  at  any  time,  an. 1 
last  from  hours  to  weeks  or  even  be  permanent,  or  mav  occur  s<-veral  tunes 
during  the  attack.  Nystagmus  is  inicomnion.  1  nllanitnatory  hvpcra'mia  of 
the  conjunctivfe  often  occurs  ;n id  may  pass  into  intense  conjiniclivitis  with 
great  tumefaction  of  th<.  li<ls.  Exceptionally  tli..  coni..a  tdceralcs  an.l  the 
globe  collai)ses.  Suppurative  irido-<-lioroidilis  or  optic  neuritis  sometimes 
occurs.        As    a  result  of  the    ocular    lesions  permanent   blindness   has  been 


174  CEBEBBO-SPINAL    FEVER. 

repeatedly  reported.  Transient  loss  of  vision  is  also  observed,  and,  it  has 
been  claimed,  may  be  one  of  the  earliest  symptoms.  The  symptoms  con- 
nected with  the  ear  are  important.  The  patients  early  become  sensitive  to 
noises,  and  often  complain  of  ringing  in  the  ears,  and  become  somewhat 
deaf  within  the  first  two  or  three  days.  These«  symptoms  are  generally 
bilateral.  A  catarrhal  inflammation  of  the  middle  ear  is  of  frequent  occur- 
rence; a  suppurative  lesion  less  common.  As  the  patient  emerges  from  the 
stupor  or  delirium  it  may  be  found  that  he  is  totally  deaf.  This  may  or 
mav  not  be  followed  by  perforation  of  the  membrana  tympani  and  purulent 
discharge.  Even  when  the  deafness  is  complete  and  lasts  for  weeks,  it  may 
gradually  subside  and  hearing  be  partly  regained. 

Alterations  of  the  skin  are  very  common  in  certain  epidemics,  though  rare 
in  others.  Their  nature,  too,  varies  with  the  epidemic.  The  tdche  cerebrale 
is  usually  to  be  obtained.  On  the  second  or  third  day,  or  occasionally  much 
later,  an  eruption  of  herpes  is  apt  to  occur.  This  usually  begins  as  herpes 
labialis.  The  individual  lesions  are  numerous  and  large  ;  often  they  become 
confluent  and  form  an  area  of  racemose  form  with  thick,  purulent  contents, 
which  soon  dry  into  crusts  of  peculiar  thickness  and  dark  color.  Not  rarely 
the  eruption  spreads  to  the  cheeks,  or  separate  patches  of  herpes  form  about 
the  nose,  eyelids,  or  ears,  and  greatly  disfigure  the  patient.  Herpes  facialis  is 
thus  more  common  in  cerebro-spinal  fever  than  in  even  malaria  or  pneumonia, 
and  although  the  large  racemose  patches  which  may  appear  on  the  chest  or 
other  parts  of  the  body  are  less  frequent  than  those  on  the  face,  tliey  are 
decidedly  more  often  observed  in  this  aifection  than  in  any  other  disease. 
Thus  they  possess  a  certain  diagnostic  value. 

Petechise  and  larger  purpuric  spots,  and  even  extensive  ecchymoses,  are 
frequent  in  some  epidemics.  They  gave  rise  to  the  name  "spotted  fever," 
and  were  formerly  regarded  as  more  characteristic  and  of  higher  diagnostic 
value  than  at  present.  I  have  repeatedly  seen  the  true  nature  of  typical 
cases  overlooked  on  account  of  the  absence  of  such  an  eruption.  It  may 
be  limited  in  extent  or  widely  diifused.  The  color  is  sometimes  bright  red 
at  first,  growing  darker  in  a  short  time,  but  is  often  dark  purple  from  the 
beginning.  The  extensive  ecchymoses  and  larger  spots  are  characteristic 
of  the  more  malignant  cases.  In  the  Philadelphia  epidemic  of  1863  an 
eruption  of  petechise  occurred  in  the  vast  majority  of  cases,  and  usually  on 
tlie  first  or  second  day,  often  indeed  within  a  few  hours  of  the  attack. 
Petechial  rashes  have  certainly  been  more  frequent  in  America  than  in 
Europe,  and  even  here  seem  oftenest  to  have  been  observed  in  the  earlier  epi- 
demics. A  dusky  surface  with  livid  mottling  may  appear  without  any  dis- 
tinctive eruption.  Among  other  eruptions  sometimes  seen  are  erythema,  su- 
damina,  urticaria,  ecthyma,  pemphigus,  and  rashes  resembling  measles  or  scar- 
latina. Erysipelas  has  been  observed.  Gangrene  of  the  skin  may  develop 
with  a  ra])idity  which  indicates  direct  disturbance  of  the  trophic  innervation. 
Several  diflferent  eruptions  often  occur  on  the  same  individual.  A  symmet- 
rical distribution  of  the  eruption  is  often  a  very  noticeable  feature.     A  marked 


DESCRIPTION    OF  lyDIVIDLALSYMPTOMS.  175 

liability  to  the  production  of  bed-sores  is  found  in  some  cases.  It  is  conse- 
quently necessary  to  guard  all  points  which  are  subjectwl  to  continuous  pres- 
sure. This  tendency  comes  at  times  from  the  profound  dyscrasia  of  the  blood, 
while  at  other  times  it  seems  rather  to  depend  on  the  impaired  trophic  iiillu- 
ence  of  special  nerves  involved  in  the  morbid  j)rocess. 

The  temperature  of  cercbro-spinal  fever  is  exceedingly  irregular,  and  there 
is  no  characteristic  curve.  The  fever  is  usuallv  moderatclv  hiirh  bv  the  second 
or  third  day,  if  not,  indeed,  upon  the  first.  Ziemsscn  places  the  average  tem- 
perature at  100.4°  to  103°  F.  In  many  c;ises,  however,  there  is  but  little 
fever,  and  it  may  be  that  only  when  the  thermometer  is  placetl  in  the  rectum 
does  an  increase  of  temperature  above  the  normal  become  manifest,  the  axilla 
and  mouth  showing  no  alteration.  The  temperature  at  the  onset  may  be  sub- 
normal a  short  time,  and  the  same  thing  may  be  observed  temporarily  later, 
as  during  the  brief  remission  occasionally  witnessed  about  the  third  day.  In 
certain  severe  cases  the  temperature  may  be  truly  hyperj>yrexial.  Wundcr- 
lich  has  recorded  it  in  one  instance  as  107.5°  F.,  and  as  still  somewhat  higher 
.shortly  after  the  death  of  the  patient.  The  curve  exhibits  variations  which 
are  great,  sudden,  and  raj)id.  It  fluctuates  remarkably  from  day  to  day,  and 
even  from  hour  to  hour,  and  there  is  no  regularity  in  the  difl'erences  between 
morning  and  evening  temperature.  Sometimes  accessions  of  pain  are  accom- 
panied by  increase  of  fever.  In  the  intermittent  form,  as  already  stated,  there 
occur  dailv  or  every  second  day  exacerbations  of  fever  with  alternating  periods 
of  apyrexia,  but  without  the  regularity  characteristic  of  malarial  infection.  The 
variations  are  apt  to  be  so  marked  in  all  forms  of  this  disease  that  when  it  does 
not  too  greatly  annoy  the  patient  it  is  well  to  take  both  the  axillary  and  the 
rectal  temperature. 

The  pulse  is  likewise  very  variable.  It  is  generally  full  and  strong  at  first, 
but  becomes  feeble  and  small  in  states  of  general  depression.  It  may  occa- 
sionally be  abnormally  slow  at  the  outset,  but  soon  increases  in  fVc(iuency,  in 
fatal  cases  becoming  too  rapid  to  permit  of  being  counted.  Its  rate  is  not  at 
all  in  proportion  to  the  elevation  of  temperature,  and  it  is  nearly  always  rapid 
in  children.  The  pulse  may  change  from  slow  to  fast,  and  vice  vcr,sd,  even 
within  a  few  minutes,  this  varial)ility  forming  a  very  constant  and  characteris- 
tic symptom  of  the  affection.     Not  infrequently  the  pulse  is  irregular. 

Palpitation  of  the  heart  is  sometimes  a  very  annoying  featuie.  Blood 
taken  from  patients  by  venesection  usually  shows  an  increase  in  tiie  amount 
of  fibrin— an  observation  which  is  explained  by  the  lixt  that  it  is  only  in 
cases  of  infiammatory  type  that  any  one  would  thiid<  nf  bhrding.  '  in  cases 
of  grave,  infectious  type  the  blood  becomes  (piickly  daik  and  dilliucnt. 

Respiration  mav  be  unaffected,  but  in  severe  cases  is  liable  t<.  Uvmuw  sigh- 
ing, labored,  intermittent,  or  slow.      In  fatal  .ms.s  it    may  assume  the  ( 'hcyuc- 

Stokes  tvpe. 

Vom'iting,  the  most  prominent  of  t lie  .iigeslive  disturbances,  is   lu   reality 

dependent  purely  upon  nervous  influences.    It  is  an  initial  symptom  verv  c.m- 
stantlv  present.     It  may  last  a  few  liours  to  one  or  two  days,  and  the,,  ,lisap- 


176  ■  CEREBROSPINAL    FEVER. 

pear,  perhaps  to  recur  later  in  the  course  of  the  attack.  It  is  often  accom- 
panied by  vertigo,  and  usually  by  faintness.  Sometimes  it  is  a  troublesome 
symptom  throughout  the  whole  sickness,  and  may  become  a  most  dangerous 
one,  on  account  of  the  exhaustion  Avhich  ensues  from  lack  of  sufficient  nour- 
ishment. Appetite  may  persist  in  full  force  in  spite  of  the  vomiting,  but  in 
other  cases  is  lost.  Taste  is  im])aired.  The  tongue  may  be  but  slightly  coated, 
and  continue  moist  throughout  the  disease,  even  though  there  may  be  decided 
hebetude  and  delirium.  This  has  seemed  to  me  to  be  in  part  due  to  the  fact 
that  the  mouth  is  less  apt  to  be  kept  open  than  in  typhus  or  typhoid  fever. 
In  cases  which  run  into  the  ty])hoid  state  the  tongue  becomes  brown  and  dry, 
and  sordes  form  freely.  The  throat  is  sometimes  inflamed.  A])hthous  sto- 
matitis has  been  reported.  Thirst  is  generally  very  great.  Inflammation  of 
the  parotid  gland  has  been  occasionally  met  with.  Jaundice  has  been  seen  in 
a  few  instances.  The  abdomen  may  be  as  strongly  retracted  as  in  tubercular 
meningitis.  I  have  frequently  seen  this  continue  for  weeks  during  the  whole 
duration  of  prolonged  cases,  occasionally  becoming  so  extreme  toward  the  close 
of  those  fatal  cases  which  run  a  very  long  course  with  great  marasmus  that 
the  spinal  column  and  the  various  abdominal  organs  might  be  felt  with  extra- 
ordinary distinctness  through  the  wasted  abdominal  walls.  On  the  other  hand, 
in  cases  of  the  ty])hoid  tyjie  distension  of  the  abdomen,  partly,  at  least,  of 
paretic  nature,  with  uncontrollable  looseness  of  the  bowels,  may  develop.  Con- 
stipation rather  than  diarrhoea  is,  however,  the  rule  in  cerebro-spinal  fever. 

The  secretion  of  urine  is  sometimes  greatly  increased,  even  when  the  tem- 
perature is  high.  The  amount  passed  is,  in  fact,  oftener  increased  than  nor- 
mal, but  is  sometimes  diminished.  Albumin  or  sugar  has  been  occasionally 
observed,  and  casts  and  blood  are  more  rarely  found.  Retention  of  urine  may 
occur  in  coma  and  necessitate  catheterization.  On  the  other  hand,  there  may 
be  incontinence.  The  spleen  is  generally  not  sufficiently  enlarged  to  produce 
an  increase  of  percussion  dulness. 

Complications  and  Sequelae. — The  complications  have  already  been  out- 
lined to  some  extent  in  the  description  given  of  the  symptoms.  Certain  others 
in  addition  to  these  may  be  passed  in  review.  Broncho-pneumonia,  croujious 
pneumonia,  pleurisy,  atelectasis,  bronchitis,  endocarditis,  and  pericarditis  are 
not  uncommon.  The  frequent  combination  of  croupous  pneumonia  with  men- 
ingitis often  renders  it  doubtful  which  is  to  be  considered  the  primary  disease 
in  any  individual  case.  It  is  certain,  at  least,  that  pneumonia  frequently 
develops  during  the  prevalence  of  epidemics  of  cerebro-s]>inal  fever,  and  that 
the  two  affections  are  often  closelv  associated.  Various  other  infectious  dis- 
eases,  as  malaria,  measles,  typhoid  fever,  scarlatina,  and  cholera,  have  occurred 
in  connection  with  cerebro-spinal  fever.  Intestinal  catarrh  is  also  seen,  and 
parenchymatous  changes  of  the  liver  and  kidneys  are  occasional  complications. 

Of  the  sequelse,  permanent  blindness  and  deafness  are  among  the  most 
important.  Cer(>bro-spinal  fever  has  been  a  very  frequent  cause  of  deaf- 
mutism,  and  careful  inquiry  will  elicit  the  fact  that  a  considerable  pro- 
portion   of  all    cases    in  institutions    for    the   deaf  and    dumb  are    traceable 


RELAPSE  AyD    EECURREXCE.— DIAGNOSIS.  177 

to  meningitis.  The  deafness  is  probably  ottenest  tlue  to  an  intiamniatoiy 
involvement  of  the  labyrinth.  Aphasia  and  imperfect  artienlation  may,  like 
the  deafness,  be  prodnced  by  the  disease.  Headache  is  often  the  most  tronble- 
some  seqnel,  persisting  for  months  or  even  years.  Mental  feebleness  is  often 
observed.  Ziemssen  regards  chronic  hydro(.'cphalns  as  a  seqnel  by  no  means 
rare.  The  symptoms  of  this  condition  consist  of  "  paroxysms  of  severe  head- 
ache, pains  in  the  neck  and  extremities,  with  vomiting,  loss  of  conscionsness, 
convulsions,  and  involuntary  discharges  of  faeces  and  urine."  He  regards 
the  prognosis  of  this  condition  as  nearly  alwavs  hopeless. 

Paralyses  of  single  extremities  or  of  the  parts  supplied  by  the  cranial 
nerves  are  not  very  uncommon.  They  depend  on  lesions  of  the  brain  or 
cord  or  of  the  nerves  themselves.  ]Most  of  the  cases  recover  after  a  few 
months ;  which  suggests  that  they  have  been  due  to  lesions  of  the  nerve- 
trunks,  and  is  confirmatory  of  the  view  that  perineuritis  and  neuritis  are 
of  common  occurrence  in  this  disease. 

Relapse  and  Recurrence. — Relapses  are  common.  They  sometimes  occur 
so  frequently,  and  prolong  the  case  to  such  an  extent,  that  a  "  chronic  form  " 
of  cerebro-spinal  fever  has  been  made  a  distinct  type  by  some  writers.  I  have, 
however,  already  expressed  the  opinion  that  more  frequently  the  jirotracted 
course  of  the  case  is  due  to  a  persistent  or  progressive  lesion,  such  as  chronic 
meningitis,  chronic  hydrocephalus,  or  even  abscess  of  the  brain.  The  occur- 
rence of  the  disease  does  not  afford  a  complete  immunity  from  a  recurrence 
of  a  second  attack.  Miner  found  several  instances  of  a  second  attack  of 
the  aifection  in  which   the  patients  had  suffered  from  it  the  year  previous. 

Diagnosis. — Ordinarily  the  diagnosis  of  cerebro-spinal  fever  is  a  matter 
of  no  great  difficulty.  Sometimes,  however,  it  is  alm(jst  impossible  in  the 
early  stage,  as  Avhen  the  disease  occurs  sporadically  or  at  the  beginning  of  an 
epidemic.  In  young  children  also,  or  when  in  combination  with  other  dis- 
ea.ses,  the  aifection  may  be  very  difficult  to  recognize. 

The  most  characteristic  features  are  the  sudden  onset  and  rapid  advance; 
prostration;  intense  pain  in  the  head,  neck,  back,  and  limbs;  vomiting;  faint- 
ness;  vertigo;  tonic  contraction  of  the  muscles  of  the  neck,  and,  later,  of  the 
back;  clonic  local  or  general  convulsive  movements  ;  hyperiesthesia ;  delirium 
alternating  with  somnolence;  very  irregular  pulse  and  temperature;  and  the 
cutaneous  eruptions.  The  diagnosis  of  mild  sporadic  cases  is  rendered  addi- 
tionally difficult  by  the  fact  that  in  these  the  crnption,  the  liypera\>^thcsia,. 
pain  in  the  back  and  extremities,  and  stilfncss  of  the  spine  may  be  mostly 
wanting,  while  the  pain  and  spasm  at  the  back  ol"  the  neck  may  not  be  as 
well  marked  as  in  the  epidemic  form. 

Several  affections  are  likely  to  be  confounded   with  cerebro-spinal   fever. 

Tubercular  menivi/ifis  very  closely  resembles  il  il"  tlie  case  is  seen  att<'r  ihc 
development  of  partial  or  com|)lete  unconsciousness,  with  stilfness  of  tlie  iieek, 
cerebral  erv,  irregular  fever  and  piil-e.  Uiil  If  tlieiv  Iims  Ikcii  an  opportunity 
to  observe  the  case  from  the  start,  it  will  be  readily  reeogni/.ed  as  one  of  tuber- 
cular nature  by  the  longer  prodromes  and  m(»re  gradual  (»nset,  with  lieadaelie, 
Vol..  I.— 12 


178  CEREBROSPINAL    FEVER. 

vomitin"-,  and  constipation  ;  the  characteristic  stages  of  alteration  of  the  pnlse  ; 
the  earlier  appearance  of  retraction  of  the  abdomen  ;  the  less  degree  of  retrac- 
tion of  the  head,  of  hypersesthesia,  and  of  pains  in  the  extremities ;  the  rarity 
of  petechial  or  herpetic  eruptions ;  the  greater  frequency  of  Cheyne-Stokes 
respiration ;  the  detection  of  choroidal  tubercles  by  the  aid  of  the  ophthal- 
moscope ;  and  the  longer  course  and  invariably  fatal  ending. 

The  cerebral  form  of  typhoid  fever  may  occasionally  simulate  cerebro-spinal 
fever  very  closely.  Cases  of  it  may  exhibit  high  fever,  headache,  delirium, 
stiffness  of  the  neck,  tremor,  and  spasm  of  the  muscles.  Ordinarily,  however, 
typhoid  fever  differs  widely  in  the  slow  onset,  absence  of  vomiting  and  of 
inuscular  spasm,  and  presence  of  continuous  hebetude,  typical  temperature 
curve,  characteristic  cutaneous  eruption,  epistaxis,  abdominal  tenderness  with 
diarrhtiea,  and  greater  enlargement  of  the  spleen. 

Typhus  fever  has  been  repeatedly  confounded  with  cerebro-spinal  fever,  and 
it  is  true  that  in  certain  epidemics  cases  present  themselves  which  are  difficult 
to  discriminate.  This  is,  of  course,  pre-eminently  the  case  when  outl)reaks  of 
the  latter  occur  in  localities  or  under  conditions  which  render  the  occurrence 
of  typhus  plausible  or  where  it  already  exists.  Between  cases  of  the  cerebro- 
spinal type  of  typhus  fever  and  of  cerebro-spinal  fever  the  points  of  resem- 
blance are  the  sudden  onset  with  rapid  development  of  delirium  and  stupor,  the 
extreme  hypersesthesia  and  muscular  soreness,  the  headache,  rigidity  of  the  cer- 
vical muscles  and  occasional  retraction  of  the  head,  and  the  occurrence  of  a 
petechial  eruption.  On  the  other  hand,  typhus  fever  is  a  highly  contagious 
disease,  which  does  not  occur  sporadically  in  this  country  nor  in  epidemic  form 
unless  in  seaports,  where  it  occasionally  spreads  from  imported  cases.  High 
initial  fever  is  almost  constant  in  typhus,  and  the  temperature  curve  is  charac- 
teristic ;  the  facies  is  distinct ;  the  eruption  is  constant,  and  appears  about  the 
fourth  day  as  a  roseolous  rash,  becoming  gradually  petechial  instead  of  occur- 
ring as  it  does,  when  present  in  cerebro-spinal  fever,  almost  at  the  very  onset 
of  the  attack;  herpes  does  not  occur  in  typhus;  vomiting  is  rare;  convul- 
sions are  much  less  frequently  seen ;  there  is  much  less  pain,  and  muscular 
rigidity  is  less   marked. 

Influenza  may  not  seem  likely  to  be  confounded  with  cerebro-spinal  fever, 
yet  there  are  points  of  striking  analogy  which  demand  attention.  These  two 
affections  are  distinguished  from  other  infectious  diseases  by  their  remarkable 
pandemic  character.  In  the  various  epidemics  of  influenza  the  utmost  variety 
in  its  manifestations  has  been  exhibited.  Although  catarrhal  irritation  of 
the  mucous  membranes,  with  fever  of  irregular  type,  is  the  usual  expression, 
there  is  a  proportion  of  cases,  varying  in  different  epidemics,  where  the  force 
of  the  disease  falls  on  the  nervous  centres,  and  cerebro-spinal  meningitis  is 
developed  with  severe  pains  of  perineuritis,  muscular  soreness,  rigidity  of 
the  cervical  muscles,  and  retraction  of  the  head,  convulsions,  delirium,  and 
stupor.  Death  is  frequent  in  these  cases,  but  when  they  recover  lesions  of  the 
organs  of  special  sense,  of  the  peripheral  nerves,  or  of  the  nervous  centres  may 
remain.     It  is  well  known  now  that  even  in  ordinary  cases  of  influenza  peri- 


DURATION,    MORTALITY,    PROGNOSIS.  179 

neuritis  is  of  frequent  occurrence.  During  the. recent  severe  epidemic  many 
cases  of  meningitis,  as  above  sketched,  have  occurred.  It  is  altogether  prob- 
able that  in  some  instances  these  were  sporadic  cases  of  cerebro-spinal  fever, 
but  it  is  also  clear  that  there  was  a  sudden  development  of  meningitis  in  other 
cases  which  were  unmistakably  influenza. 

Eheumatic  fever,  with  little  or  no  joint  iuvolvement,  but  with  muscular 
soreness  and  rigidity,  retraction  of  the  head  or  trismus,  aud  with  marked 
cerebro-spinal  symptoms,  either  connected  with  hyperpyrexia  or  with  actual 
meningeal  irritation,  may  occasionally  closely  simulate  cerebro-spinal  fever. 
It  undoubtedly  ha})pens  that  at  times  cerebro-spiual  rheumatism  is  regarded 
as  cerebro-spinal  fever,  and  the  reverse. 

Pernicious  malarial  fever  may  resemble  malignant  cerebro-spinal  fever  in 
the  rapid  development  of  collapse  and  coma.  It  can  be  distinguished  from  it 
by  the  consideration  of  the  etiological  circumstances  and  by  the  fact  that  the 
first  malarial  paroxysm  rarely  exhibits  the  malignant  character.  Tiie  detection 
of  the  malarial  organism  in  the  blood,  the  greater  enlargement  of  the  spleen, 
and  the  specific  effect  of  quinine  properly  administered  will  establish  the 
diagnosis. 

Malignant  scarlet  fever  may  occasionally  resemble  cerebro-spinal  fever  in 
the  sudden  onset  with  high  temperature,  vomiting,  convulsions,  and  stupor. 
Its  presence,  however,  may  be  suspected  from  the  early  redness  of  the  fauces. 
The  appearance  of  the  scarlatinal  rash  settles  the  ditliculty  unless  death  takes 
place  before  this  occurs. 

Small-pox  may  also  be  mistaken  for  it,  the  resemblance  being  in  the  severe 
pain  in  the  back  and  head,  in  the  vomiting,  and  in  the  development  of  a  pur})uric 
rash  in  some  cases.  The  papular  character  of  the  eruption  and  the  general 
course  of  the  disease  aid  in  distinguishing  it. 

During  epidemics  of  cerebro-spinal  fever  occasional  cases  are  noted  where 
death  occurs  in  a  few  hours,  when  there  has  been  little  or  no  rise  of  tempera- 
ture, but  such  extensive  appearance  of  petechite  and  ecchymoses  as  to  raise  the 
question  of  the  fulgurant  type  of  purpura. 

Meningitis  secondanj  to  croupous  pneumonia  and  other  acute  diseases  is  with 
difficulty  distinguished  from  cerebro-spinal  fever.  In  the  cerebral  form  of 
pneumonia,  whether  a  true  meningitis  or  a  jiseudo-meningitis  be  present,  there 
are  often  considerable  tremor  and  muscular  spasm,  but  tlie  stilfness  of  the 
nuiscles  of  the  neck  and  back  and  the  hyperesthesia  are  not  so  marked.  In 
some  cases,  however,  it  may  be  very  difficult  to  determine  whether  wc  have 
to  do  with  pneumonia  complicated  by  meningitis  or  with  (vrcbro-spinal  fever 
complicated  by  pneumonia. 

Mild  cases  of  cerebro-spinal  fever  have  sometimes  hrvu  mistaken  for  hi/s- 
teria,  but  the  severe  pain,  the  muscular  rigidity,  and  the  occurrence  of  fever 
should  prevent  the  mistake. 

Duration,  Mortality,  Prognosis.— The  <-ourse  of  tlie  diseas."  is  v.>ry 
variable.  Jn  the  mikler  forms  and  in  tlie  ,„ost  malignant  variety  tl..' 
duration    varies    from    a    few  hours  to  five  days.       The    moderately    severe 


180  CEREBROSPINAL    FEVER. 

cases  begin  to  recover  after  one  or  two  weeks,  but  may  be  prolonged  fur 
months.  Convalescence  is  comparatively  slow  and  subject  to  many  inter- 
ruptions from  complications  and  sequelse.  The  first  week  of  the  disease  is 
usually  the  time  of  greatest  danger,  and  patients  who  live  until  the  close  of 
the  second  week  will  probably  recover.  At  the  same  time,  the  prognosis  in 
any  individual  case  is  a  matter  of  the  greatest  uncertainty,  both  as  regards  life 
itself  and  as  regards  the  persistence  of  permanent  danger  of  some  part.  In 
moderately  severe  cases  no  prognosis  at  all  can  be  made  for  some  days,  and 
even  then  it  must  be  most  guarded.  Malignant  cases  nearly  always  die,  but 
even  to  this  there  are  exceptions.  Mild  and  abortive  cases  generally  recover, 
but  here,  too,  a  guarded  prognosis  must  be  given.  Under  five  years  and  over 
thirty  years  of  age  the  prognosis  is  less  favorable  than  between  these  periods. 
In  children  under  two  years  of  age  the  rate  of  mortality  and  the  danger  of 
grave  sequels  reach  the  highest  point. 

Symptoms  generally  unfavorable  are  abrupt  and  violent  onset,  evidences 
of  great  excitement,  hyperpyrexia,  coma,  convulsions,  great  prostration  of 
strength  early  in  the  affection,  irregular  respiration,  unusually  intense  head- 
ache, persistent  vomiting,  evidences  of  extensive  disorganization  of  the  blood. 
The  occurrence  of  complications,  especially  those  connected  with  the  lungs, 
increases  the  gravity  of  the  prognosis. 

The  mortality  of  cerebro-spinal  fever  is  very  great,  varying  much  in  differ- 
ent epidemics.  Ziemssen  places  it  at  30  per  cent,  for  mild  epidemics  and  over 
70  per  cent,  for  the  most  severe  ones,  the  general  mortality  averaging  40  per 
cent. 

Treatment. — Prophylaxis. — Little  can  be  done  in  the  line  of  prophylaxis, 
inasmuch  as  we  know  so  little  regarding  the  cause  of  the  affection.  The  avoid- 
ance of  unsanitary  conditions  in  streets  and  houses  is  of  course  an  important 
matter.  It  is  also  advisable  that  the  inmates  pf  a  house  in  which  the  disease 
has  broken  out  should  leave  it  until  after  the  epidemic  is  over,  since  there 
sometimes  seems  to  be  a  tendency  for  the  affection  to  spread  in  families. 
Linen  used  about  the  patient  should  be  disinfected  or  destroyed.  As  in  the 
case  of  other  serious  infectious  disease,  it  is  important  during  an  epidemic  of 
cerebro-spinal  fever  to  avoid  fatigue  of  any  sort,  to  lead  as  quiet  a  life  as  pos- 
sible, and  to  preserve  the  general  health  in  the  best  possible  condition.  Indeed, 
it  is  to  be  recommended  that  persons  in  poor  health  leave  the  locality  while  the 
epidemic  lasts. 

Treabaent  of  the  Attack. — The  great  variety  of  type  in  different  epidemics 
and  in  different  cases  in  the  same  epidemic,  and  the  highly  complex  grouj)  of 
symptoms  presented,  explain  the  impossibility  of  formulating  any  uniform 
plan  of  treatment.  It  is  necessary  in  each  individual  case  to  adapt  our  rem- 
edies to  the  grade  and  to  the  special  localization  of  the  morbid  process. 

The  room  should  be  kept  dark  and  quiet.  The  diet  should  consist  of 
easily  assimilable  liquid  substances,  given  freely  and  often,  since  the  disease  is 
one  in  which  exhaustion  so  readily  supervenes,  and  in  which  there  is  rarely 
any  lesion  of  the  gastro-intestinal  tract.     As  soon  as  the  fever  has  abated  solid 


TREA  TMEXT.  1 8 1 

food  should  be  administered.  Watei'  is  to  be  ffiven  freelv  at  all  times.  In 
many  cases  the  obstinate  cerebral  vomiting  interferes  with  the  administration 
of  food  at  first,  and  in  such  nutrient  enemata  may  be  employed.  It  is  often 
difficult  to  secure  the  ingestion  of  enough  food,  but  I  have  never  found  it 
necessary  to  resort  to  forced  feeding  by  means  of  a  stomach-tube.  Even  when 
prostration  is  apj^arently  not  great,  the  patient  should  not  assume  the  erect 
position  in  bed,  as  dangerous  syncope  may  follow.  Until  convalescence  is 
complete  all  exertion  and  excitement  nuist  be  shunned,  and  a  return  to  the 
ordinary  methods  of  life  is  well  deferred  for  some  time. 

A'enesection  was  early  advocated,  and  the  sym])toms  of  acute,  intense  cere- 
bro-spinal  irritation  often  suggest  it  forcibly.  It  must  be  remembered  that 
when  fever  is  high  the  blood  becomes  rai)idly  disintegrated,  and  such  pro- 
found debility  soon  develops  as  to  render  depletion  dangerous.  In  young  chil- 
dren, also,  it  is  nearly  always  inadmissible,  and  even  local  bleeding  has  been 
followed  by  alarming  depressi(m.  On  the  other  hand,  in  the  onset  of  cases  of 
sthenic  type,  where  the  pyrexia  was  moderate  and  the  pain  and  cerebro-sjiinal 
irritation  were  extreme,  I  have  bled  healthy  adults  with  great  advantage,  liiid- 
ing  the  blood  highly  coagulable.  The  prompt  relief  afforded  to  the  pain  and 
central  congestions  has  been  followed  by  improvement  in  the  force  and  volume 
of  the  pulse.  In  carefully  selected  cases  I  would  therefore  advise  moderate 
venesection  soon  after  the  onset.  AVhen  the  propriety  of  this  is  doubtful,  as 
in  delicate  or  voung  persons,  when  the  fever  is  high,  or  when  the  first  day  or 
two  has  passed,  wet  cups  or  leeches,  or  even  dry  cups  alone,  may  be  applied 
to  the  temples,  the  mastoid  regions,  the  nape  of  the  neck,  or  along  the  spinal 
colunni. 

Cold  to  the  head  and  spine  is  a  valuable  therapeutic  measure.  It  should 
be  applied  for  hours  continuously  in  the  form  of  ice-bags  or  in  Leiter's  tubes. 
Cold  aifusions  or  cold  sponging  may  be  substituted  sometimes.  Cold  is  par- 
ticularly useful  in  the  early  stages  when  pain  in  the  head  is  at  its  worst.  It 
often  decidedly  relieves  the  suffering  and  ])roduces  quiet  sleej).  Tiie  applica- 
tion should  be  renewed  as  often  as  pain  returns.  Cold  baths  to  reduce  tem- 
perature may  be  given  systematically  if  the  fever  be  high.  As,  however, 
the  temperature  is  rarely  either  high  or  ai)parently  ]u-ov(i<':itive  of  dangerous 
symptoms,  this  measure  is  not  often   indicated. 

Moist  or  drv  heat  locally  applied  is  of  value  botli  in  mitigating  violent 
symptoms  and  in  anticipating  or  removing  the  colla])se  which  is  so  apt  to 
come  on  in  this  disease.  Hot  mustard  foot-l)aths,  hot  bottles,  bricks,  or  sand- 
bags, hot  moist  flannels  and  the  like  are  all  useful  ior  this  purjx.se.  It  is 
well  to  apply  heat  to  the  rest  of  the  body  wliile  cold  is  being  used  about  the 
head  and  spine.     In  this  way  any  depressing  effect  of  the  cold  is  prevented. 

Blisters  have  long  been  employed  to  reliev*'  pniii  :ind  to  lessen  congestion. 
It  is  true  that  sometimes  they  seem  to  <limiiii-h  pain,  delirium,  spasms,  and 
coma.  It  is  questionable,  however,  whether  they  are,  as  a  rule,  of  any  lasting 
benefit,  while,  on  the  other  hand,  they  an-  lial.l."  to  add  to  the  aiuioyance  and 
sulferi.'iL^  of  the  patient.      If  used   at   all,  tli.y  shouhl   be  applie.i  at   the  back 


182  CEREBROSPINAL    FEVER. 

of  the  neck  very  early  in  the  disease,  and  should  be  allowed  to  vesicate  snper- 
ficiallv  onlv.  It  is,  however,  in  my  judgment,  much  safer  and  more  efficient 
to  use  light  applications  of  the  thermo-cautery  over  the  mastoid  or  at  the  nape 

of  the  neck. 

Alcohol  is  often  of  the  greatest  value.  Many  cases  do  not  need  it  at  any 
time,  and  those  of  an  inflammatory  type  may  be  injured  by  it  if  administered 
at  the  onset ;  but  its  use  should  be  promptly  commenced  when  there  is  the 
slio-htest  siffu  of  exhaustion.  The  amount  administered  should  in  every  case 
depend  upon  the  effect  produced,  care  being  taken  that  too  much  is  not  given, 
althouo-h  patients  with  cerebro-spinal  fever  often  bear  unusually  large  amounts. 
If  under  its  use  the  pulse  grow  stronger  and  the  heart-sounds  better,  stimu- 
lants are  doing  good ;  but  if  excitement  increase  and  the  heart  beat  more 
rapidly,  the  stimulants  must  be  diminished  or  entirely  withdrawn. 

Opium  is  the  drug  upon  which  the  greatest  reliance  is  placed  by  the  major- 
ity of  writers.  Its  use  began  with  American  physicians,  but  has  since  become ' 
widely  extended.  It  may  be  given  by  the  mouth  or  rectum,  or,  in  the  form 
of  morphine,  hypodermically.  The  tolerance  for  it  in  this  disease  is  remark- 
able. As  much  as  the  equivalent  of  a  grain  of  opium  hourly  may  be  required 
in  severe  cases,  and  even  larger  doses  have  been  given.  The  drug  lessens 
the  spasm,  pain,  hyperesthesia,  and  sleeplessness,  and  strengthens  and  re- 
tards the  pulse.  Its  employment  must  be  commenced  early  in  the  disease, 
and  the  dose  must  be  repeated  and,  if  necessary,  increased  until  the  severe 
symptoms  come  under  control.  As  already  stated,  in  severe  cases  of  sthenic 
type  in  vigorous  adults  a  moderate  venesection  may  be  used  at  the  outset  with 
marked  relief  to  the  suffering  and  with  the  effect  of  rendering  the  action  of 
opiates  much  more  efficacious  in  doses  smaller  than  are  usually  required. 

The  action  of  opium  must  be  carefully  watched,  especially  in  children.  I 
have  usually  found  the  best  results  from  the  administration  of  a  hypodermic 
injection  of  morphine  and  atropine  morning  and  evening,  followed  up  in  the 
intervals  by  the  use  of  deodorized  tincture  of  opium  in  appropriate  doses  as 
indicated  by  pain  and  restlessness.  It  is  possible  that  the  relaxing  effects  of 
the  opiate,  associated  with  the  action  of  cold  and  derivatives,  may  exert  some 
influence  in  lessening  the  amount  of  meningeal  exudation.  After  effusion 
begins  o])ium  is  of  much  less  value  and  the  dose  must  be  diminished. 

Mercury,  given  in  the  hope  of  influencing  meningeal  inflammation,  is  now 
generally  considered  to  be  of  no  value  in  the  early  stage,  though  formerly 
much  used  for  this  purpose.  Ziemssen  recommends  it  both  by  inunction  and 
internally,  but  admits  that  it  is  doubtful  whether  it  exerts  any  beneficial  influ- 
ence.    It  is  of  much  greater  value  in  the  treatment  of  the  sequelae. 

Quinine  in  very  large  doses  has  been  tried,  but  there  is  no  evidence  that  it 
exerts  any  definite  effect,  even  in  the  intermittent  form  of  the  disease.  There 
is  danger,  too,  that  it  may  disturb  the  digestion,  as  well  as  exert  a  depressing 
action.  In  moderate  doses  it  may  be  used  for  its  tonic  action  in  the  form  of 
suppository  or  enema.  1  often  direct  with  apparent  advantage  a  suppository 
morning  and  evening,  containing  10  grains  each  of  quinine  and  asafoetida. 


TREA  TMENT.  1 83 

Ergot  and  belladonna  have  been  employed  on  account  of  their  ])o\ver  to 
lessen  congestion  of  the  cerebro-spinal  capillaries.  Although  favorable  results 
have  been  reported,  there  does  not  seem  to  be  good  reason  to  attribute  them  t«) 
the  action  of  these  remedies.  Rosenthal  believes  that  belladonna  must  be 
given  with  great  caution.     lu  small  doses  it  may  be  combinetl  with  opiiun. 

Calabar  bean  was  recommended  bv  N.  S.  Davis  on  the  p-round  that  it  was 
useful  in  tetanus.  Cannabis  Indica,  gelsemium,  chloral,  inhalations  of  chloro- 
form or  ether,  bromide  of  potassium,  aconite,  and  veratrum  viridc  have  all  had 
their  advocates.  Certain  of  them,  as  chloral,  aconite,  veratrum,  and  chloro- 
form, are  certainly  dangerous  in  a  disease  in  which  severe  depression  so  readily 
develops.  Inhalations  of  ether  can  be  safely  employed  in  very  bad  cases  in 
order  to  give  temporary  relief  from  extreme  restlessness,  convulsions,  or  great 
pain.  Bromide  of  potassium  is  sometimes  of  value,  particularly  in  children  and 
in  the  milder  cases ;  but  in  doses  sufficient  to  exert  a  decided  effect  in  severe 
cases  it  is  depressing  to  the  general  strength  of  the  patient.  It  may  be  advan- 
tageously combined  with  opium, 

Antipyrine,  phenacetin,  and  drugs  of  this  class  would  naturally  suggest 
themselves  on  account  of  the  severe  pains,  but  they  must  be  used,  if  at  all, 
only  with  caution  and  close  watching.  Unless  decided  relief  follow  moderate 
doses  at  rather  long  intervals,  it  is  safer  to  omit  them.  Their  administration 
must  never  be  pushed. 

Any  tendency  to  exhaustion  or  collapse  may  be  treated  by  ammonia,  tur- 
pentine, digitalis,  and,  as  already  stated,  by  alcohol  and  heat.  Ilyjioderniic 
injections  of  ether  may  be  required  to  favor  reaction  from  the  condition  of  col- 
lapse. The  urinary  bladder  must  be  watched  so  as  to  guard  against  retention. 
The  formation  of  bed-sores  must  also  be  anticipated  and  prevented  by  proper 
measures. 

As  soon  as  the  acute  stage  declines  it  is  well  to  give  potassium  Iodide 
to  favor  the  absorption  of  exudation  and  thickening.  In  conjimction  with 
tonics,  sucii  as  strychnine,  iron,  arsenic,  cod-liver  oil,  its  use  may  he  con- 
tinued during  convalescence.  When  serious  sequelae,  as  deafness,  blindness, 
perineuritis,  persistent  neuralgic  pains,  paresis,  or  evidences  of  exudation  or 
effusion,  indicate  a  continuance  of  morbid  action,  it  is  well  to  associate  mer- 
curial inunctions  with  the  internal  use  of  potassium  iodide,  and  to  cinj)loy 
repeated  blisters  or  applications  of  the  thermo-cautery  at  proper  inti-rvals. 
Electricity,  hydrotherapy,  rigid  dietetics,  and  hygiene  arc  also  of  great  value. 
I  have  frequently  seen  the  ])aticnt  use  of  such  combined  treatment  foUowed 
by  the  slow  disappearance  of  sequels  which  threatened  to  be  ])crmanent. 


INFLUENZA. 

By  WILLIAM  PEPPER. 


Influenza  is  an  acute  raicrobic  fever,  moderately  contagious ;  sporadic, 
epidemic,  and  pandemic;  associated  with  catarrhal  inflammation  of  the  mucous 
membranes  and  with  disturbance  of  the  nervous  centres  and  trunks  ;  often  run- 
ning a  short  and  favorable  course,  but  apt  to  be  attended  with  many  serious 
complications  and  sequelae. 

Synonyms. — As  might  be  expected  from  its  widesjjread  prevalence  and 
from  its  peculiar  features,  few  diseases  have  had  so  many  names  bestowed  upon 
them.  Some  of  these  names  refer  to  a  supposed  geographical  origin  of  the 
disease,  as  the  Chinese,  Russian,  or  Spanish  catarrh.  Others  refer  to  the  epi- 
demic or  contagious  nature  of  the  catarrh  which  is  so  prominent  among  its 
symptoms  :  thus,  epidemic  catarrhal  fever,  and  its  Latin  and  French  equiva- 
lents, catarrhus  a  contagio,  and  many  analogous  terms.  Many  descriptive 
names  have  come  into  popular  use,  not  a  few  of  Avhich  refer  to  the  fancied 
insignificance  of  the  disease  as  observed  in  mild  epidemics.  The  events  of  the 
past  few  years  have,  however,  secured  both  professional  and  popular  approval 
of  three  names  only — influenza,  an  old  name  of  Italian  origin,  given  in  allu- 
sion to  the  part  played  by  astral  or  atmospheric  influence  in  the  causation  of 
the  disease  ;  la  grippe,  derived  from  the  French  verb  gripper,  to  seize ;  and 
grip,  the  familiar  English  equivalent.  Gripped,  grippal,  to  be  gripped, 
grippo-toxine,  and  so  forth,  are  terms  whose  convenient  brevity  may  secure 
their  continued  use. 

History,  Nature,  and  Causation. — It  is  altogether  probable  that  extensive 
epidemics  of  influenza  have  prevailed  from  the  earliest  ages,  though  it  may  be 
admitted  that  the  first  accurate  descriptions  of  the  disease  date  back  only  to  the 
beginning  of  the  sixteenth  century.  Since  then  there  have  been  frequent  epi- 
demics, not  a  few  of  which  have  spread  rapidly  over  entire  continents,  and 
have  appeared  almost  simultaneously  in  widely  distant  countries.  Repeated 
outbreaks  have  occurred  in  America  since  at  least  1655.  Careful  study  of  the 
annals  of  influenza  proves  conclusively  the  identity  of  the  disease  with  all  its 
protean  manifestations  from  the  date  of  the  earliest  records  down  to  the  last 
great  epidemic,  which  seems  to  have  broken  out  in  Bokhara  in  May,  1889.  It 
had  established  itself  in  St.  Petersburg  in  October  of  the  same  year ;  it  was 
recognized  in  Paris  as  early  as  November ;  England  was  invaded  early  in 
November,  if  not  in  October ;  cases  began  to  be  of  frequent  occurrence  in 
America  toward  the  close  of  October  or  in  November.  The  epidemic  reached 
its  height  at  almost  the  same  date  in  January  and  February  of  1890  in  widely 

184 


HISTORY,    NATURE,    AND    CAUSATION.  185 

distant  localities;  smouldered  away  durinir  the  ensuing  sumuier,  onlv  to 
awaken  to  renewed  activity  in  the  late  autumn  of  that  year,  and  to  prevail 
extensively  until  the  spring  of  J 891,  when  it  again  subsided,  hut  for  a  third 
time  revived,  in  milder  and  less  prolonged  form,  in  tiie  winter  of  1891-92, 

In  the  intervals  of  epidemic  waves  of  influenza  there  occur  in  many,  if  not 
in  all,  large  towns  and  thickly-populated  districts  sporadic  cases  which  present 
all  the  features  of  the  disease.  It  is  probable  that  carefid  bacteriological  study 
will  identify  the  nature  of  these  cases,  whicli  may  be  due  to  the  action  of  the 
specific  cause  of  iniluenza  in  a  comparatively  feeble  form,  so  that  it  can  aflect 
only  those  who  are  specially  susceptible. 

The  anak)gies  between  influenza  and  the  infectious  fevers  of  ascertained 
microbic  origin  are  so  close  that  for  a  long  time  the  existence  of  a  siK'cific 
micro-organism  has  been  assumed  as  its  effective  cause. 

Early  in  this  year  (1892)  PfeifFer,  working  at  the  Hygienic  Institute  of 
Berlin,  discovered  in  the  sputa  of  influenza  numbers  of  a  bacillus  which  he 
was  soon  able  to  recognize  as  characteristic  and  to  cultivate.  The  bacillus  of 
Pfeifier  is  a  short  organism  about  one-half  the  length  of  the  bacillus  of  raouse- 
septicseraia,  and  nearly  the  same  thickness  as  the  latter.  It  stains  with  dif- 
ficulty, but  may  be  well  shown,  by  using  Ziehl's  carbol-fuchsin  or  with  other 
stains,  to  consist  of  two  bulbous  ends  joined  by  a  narrower  and  less  intensely 
staining  central  shaft.  It  might  easily  be  mistaken  for  a  diplococcus  if  care 
were  neglected  and  the  examination  made  hurriedly. 

The  bacillus  occurs  abundantly  in  the  sputum,  and  is  said  to  have  distinct 
relation  in  number  to  the  severity  of  the  disease,  and  to  disappear  with  cessa- 
tion of  the  fever  and  cure  of  the  disease.  It  has  never  been  shown  to  be 
present  in  any  other  malady. 

In  the  lungs  Pfeiff'er  showed  that  it  penetrates  to  the  peribronchial  connec- 
tive tissue  and  to  farther  outlying  portions  of  the  huigs. 

It  was  demonstrated  in  the  blood  of  20  consecutive  cases  at  the  ^Moabit 
Hospital  of  Berlin  by  Canon,  and  since  then  in  many  other  cases  by  compe- 
tent persons. 

It  has  been  cultivated  in  agar  containing  a  small  percentage  of  sugar,  and 
grows  as  small  watery  droplets  along  the  line  of  inoculation.  It  could  easily 
be  overlooked.  It  grows  scantily  in  bouillon,  which  remains  clear.  It  can- 
not be  cultivated  in  gelatin,  as  it  requires  temi)eratures  which  li(|uefy  gelatin. 
Letzerich  used  potatoes,  finding  a  temporary  growth.  The  bacillus  was  culti- 
vated by  Kitasato,  who  fully  substantiates  Pfeitfer's  statements,  to  the  fif- 
teenth generation,  when  it  still   presente<l   its  characteristic  features. 

Inoculation  has  been  repeatedly  practised.  Apes  and  rabbits  get  (|uite 
typical  influenza.  Cornil  and  Chantemesse  injected  some  of  the  ciiltiu-cs  into 
the  anterior  chamber  of  a  rabbit's  eye,  and  soon  foinid  the  Itacilii  in  llic  blood. 
Some  of  the  latter,  mixed  with  sterile  sugar-agar  for  twciity-lbur  li(Mirs,  was 
introduced  into  a  monkey's  nose,  soon  causing  coryza,  fever,  depressicm,  i)nt 
not  death,  the  bacilli  being  present  in  llir  bmn.'liinl  .•md  n:i-:ii  nnicns.  Mice 
succumbed  to  inoculation,  and  the  bacilli  wric  found  in  tlic  congested  viscera. 


186  INFLUENZA. 

The  observations  of  Pfeiffer  have  been  confirmed,  among  others,  by  Kita- 
sato,  Canon,  Cornil,  Ciiantemesse,  Babes,  and  Letzerich.  The  last  named 
examined  the  sputa  of  50  cases  not  influenza,'and  failed  completely  to  demon- 
strate influenza  bacilli.     In  no  genuine  case  has  Pfeitfer  failed  to  find  them. 

Canon  finds  tiiem  in  the  blood  as  clumps  of  ten  or  twenty,  sometimes 
fewer.  He  stains  with  solutions  of  eosin  and  methyl  blue  in  alcohol.  The 
bacilli  stain  blue,  the  red  corpuscles  pink. 

The  isolation  of  the  bacillus  of  influenza  does  not  by  any  means  clear  up 
all  the  difficulties  as  to  its  remarkable  outbreaks.  It  would  seem  as  though 
no  ordinary  mode  of  propagation  by  contagion  and  by  fomites  could  explain 
its  almost  simultaneous  appearance  at  widely-distant  points  'and  its  wonder- 
fully rapid  spread  throughout  large  communities.  The  micro-organism  may 
be  almost  universally  distributed,  but  capable  under  ordinary  circumstances  of 
causing  only  occasional  sporadic  cases,  while  under  special  atmospheric  or  tel- 
luric conditions  it  acquires  a  degree  of  virulence  that  renders  all  subject  to  its 
attacks.  It  would  seem  that  the  suscej)tibility  to  this  poison  is  more  general 
than  in  the  case  of  any  other  infection  save  that  of  variola. 

The  evidence  is  clear  that  the  disease  is  readily  communicated  by  contagion. 
It  is  possible  that  the  specific  poison  can  be  carried  by  fomites,  and  there  are 
instances  where  it  seems  to  have  been  conveyed  by  the  corpse  of  the  patient 
dead  of  influenza.  It  appears  that  it  is  received  into  the  system  by  means  of 
the  inspired  air,  or  at  least  there  is  as  yet  no  evidence  to  show  that  water  or  milk 
can  convey  it.  It  must  be  remembered  that  the  early  scattered  cases  which 
precede  a  great  outbreak  may  be  overlooked  as  to  their  real  nature,  and  the 
seeds  of  the  disease  be  gradually  distributed,  so  that  when  the  conditions 
favorable  to  its  active  development  arise  there  is  already  widespread  prep- 
aration. 

There  are  no  known  conditions  of  climate,  soil,  elevation,  or  season  which 
affect  it.     It  has  occurred  at  sea  as  well  as  in  the  driest  localities. 

It  is  well  known  that  epizootics,  or  epidemics  of  catarrhal  nature,  have 
Occurred  frequently  among  domestic  animals.  The  exact  nature  of  these 
infectious  diseases  is,  however,  not  established  with  accuracy ;  nor  is  the  evi- 
dence clear  as  to  their  transmission  to  the  human  subject,  nor  as  to  the  acqui- 
sition by  animals  of  influenza  from  man. 

During  the  prevalence  of  an  epidemic  of  influenza  all  are  liable  to  be 
affected.  Young  children  are,  however,  less  frequently  and  less  seriously 
attacked  than  older  persons.  On  the  other  hand,  aged  and  infirm  persons, 
those  of  nervous  temperament,  and  those  whose  vitality  is  depressed  by 
fatigue  and  anxiety,  are  specially  liable ;  but  the  most  robust  health  does  not 
give  immunity. 

Relapses  of  the  disease  are  common,  and  second,  third,  or  even  more 
numerous  attacks  in  one  individual  may  be  noted.  The  susceptibility  of  the 
system  during  and  immediately  after  an  attack  is  extraordinary,  and  slight 
ex])osure  or  exertion  may  induce  grave  complications  with  startling  rapidity 
and  violence. 


MORBID  AXATOMY.— GENERAL   CLINICAL  DESCRIPTION.     187 

Morbid  Anatomy. — There  are  no  anaiuiniral  lesions  cliaractori.stic  of 
infiuenza.  The  bacilli  now  regarded  as  associated  in  the  production  of  the 
disease  are  found  in  the  sputum,  the  tissue  of  the  luncjs,  and  in  the  blood.  In 
the  great  majority  of  uncomplicated  cases  recovery  follows.  If  death  occni-s 
from  the  intensity  of  the  fever  or  from  debility,  catarrhal  iiiHauimation  of 
the  respiratory  and  digestive  mucous  membranes  is  found,  with  the  onlinary 
changes  of  congestion  and  swelling.  The  intestinal  glands  are  but  slightly, 
if  at  all,  enlarged.  The  disease  may,  however,  at  the  very  onset  excite  pneu- 
monia or  meningitis,  or  these  may  supervene  as  complications  ;  and  in  the  same 
list  must  be  ])laced  nephritis.  Tiie  pneumonia  may  be  either  lnl)nlar  or  hibar: 
even  in  the  lobar  form  both  lungs  are  often  involved  and  the  lesions  mav  be 
unusually  extensive.  Plastic  pleurisy  is  commonly  associated  with  the  pneu- 
monia. Pleurisy  with  sero-fibrinous  or  purulent  exudate  also  occurs  intlcin-nd- 
ently.  Purulent  pericarditis  was  observed  with  uiuisual  frequency  during  the 
recent  epidemic  of  influenza. 

But  few  autopsies  have  been  made  of  cases  complii-atcd  with  cerebro- 
spinal meningitis,  but  it  can  scarcely  be  doubted  that  this  lesion  is  actually 
present  in  not  a  few  instances.     Perineuritis  is  of  conmion  occurrence. 

General  Clinical  Description. — So  varied  are  the  phenomena  of  influenza 
that  it  is  difficult  to  present  a  brief  sketch  of  its  symptoms.  The  main  fea- 
tures in  a  majority  of  cases  in  most  epidemics  are  a  sudden  onset  \\\{\\  chill 
of  moderate  severity  ;  fever,  which  comes  on  quickly,  does  not  usually  exceed 
103°  F,,  pursues  an  irregular  course  of  from  four  to  seven  days'  duration,  and 
tends  to  terminate  by  crisis;  naso-])haryngeal  and  bronchial  catarrh,  with 
sneezing  and  coughing;  headache  and  pains  in  the  back,  with  myalgic  pains 
in  the  trunk  and  limbs,  and  with  a  general  soreness  as  though  bruised  or 
beaten  ;  depression  of  spirits,  with  great  malaise  and  restlessness ;  markeil 
general  and  cardiac  debility  ;  slight  enlargement  of  the  spleen  ;  absence  of 
characteristic  eru  ption. 

In  all  epidemics  there  are  many  cases  of  a  type  so  mild  that  the  patients 
pay  little  or  no  attention  to  the  attack,  regarding  it  as  an  ordinary  catarrhal 
cold,  and  continuing  at  their  usual  avocations.  It  is  impossible  to  estimate  the 
number  of  such  cases,  hut  it  is  certainly  extremely  large  in  some  outbreaks. 
In  spite  of  the  apparent  mildness  of  the  attack,  the  temperature  will  olten  be 
found  much  elevated.  During  the  epidemics  of  1889-00  and  18<J0-!>1  it 
was  common  to  have  patients  come  to  physicians'  offices  or  to  And  |)atients 
walking  abont  their  houses  with  a  temperature  of  from  102i°  to  104°.  A 
widespread  fcl)rile  tendency  exhibited  itself;  the  most  trivial  ailments  were 
attended  with  high  fever;  the  entire  poj)ulation  seemed  to  be  infected.  'IMiere 
was  danger  of  a  sudden  development  of  grave  or  rapidly  fatal  com|)lieati(.iis 
even  in  the  mildest  cases  if  exertion  and  ex])osnre  were  <'ontiniie<l.  Doubtless 
many  instances  which  .seemed  like  the  sudden  on.set  of  malignant  infection  were 
really  of  the  above  nature. 

Cases  of  grave  or  malignant  type  do,  however,  <K-eur  in  varying  proportion 
in  mo.st  epidemics.     Sometimes  the  character  of  an  outl)rr:d<  is  so  uniformly 


188  INFLUENZA. 

grave  that  the  cases  bear  but  little  superficial  resemblance  to  the  common  con- 
ception of  influenza.  The  unusual  severity  of  the  infection  shows  itself  by 
hyperpyrexia,  alarming  prostration,  or  the  early  development  of  dangerous 
pulmonary,  nervous,  or  gastro-intestinal  lesions,  or  by  a  profound  blood- 
dyscrasia  from  the  intense  virulence  of  the  poison. 

In  addition  to  these  varying  degrees  of  gravity  it  is  essential  to  recognize 
the  fact  that  influenza  manifests  itself  only  in  a  proportion,  though  a  large 
one,  of  all  cases  by  catarrh  of  the  respiratory  tract,  while  in  others  it  appears 
as  an  acute  gastro-intestinal  catarrh  ;  and  in  still  a  third  group  marked  disturb- 
ances of  the  cerebro-spinal  functions  constitute  the  prominent  symptoms. 

Certain  cases  pt-esent  one  or  the  other  of  these  aspects  exclusively,  but  for 
the  most  ])art  there  is  a  blending  of  the  various  phenomena.  This  is  most 
notably  so  in  the  case  of  the  nervous  element,  which  is  so  generally  pronounced 
as  to  have  led  many  observers  to  consider  the  localization  of  the  infectious  pro- 
cess in  influenza  essentially  in  the  cerebro-spinal  axis,  and  the  widespread 
functional  disturbances  or  serious  lesions  of  other  organs  to  be  secondary 
results  of  impaired  nervous  action. 

In  the  thoracic  form  catarrhal  symptoms  are  prominent,  coryza  is  usually 
marked,  and  the  cough  is  severe,  paroxysmal,  and  painful.  The  pain  is 
referred  to  the  substernal  region,  and  there  are  sharp  myalgic  pains  about  the 
chest.  The  sputa  are  scanty  and  tenacious.  There  is  often  a  marked  sense 
of  oppression.  The  physical  signs  consist  of  irregularly  distributed  rales, 
large  and  small,  crackling  in  character  for  the  most  part,  which  often  change 
their  location  and  quality  very  rapidly.  The  respiratory  murmur  is  apt  to  be 
feeble.  The  fever  is  moderate,  and  the  pulse-respiration  ratio  not  greatly  dis- 
turbed unless  complications  ensue.  The  tongue  is  coated  yellow,  but  remains 
moist;  appetite  is  impaired,  but  thirst  is  usually  marked.  The  bowels  are 
quiet  and  the  abdomen  normal.  Headache  is  common.  Insomnia  is  a  fre- 
quent and  distressing  symptom,  but  delirium  is  rare.  There  is  a  sense  of 
profound  weakness,  and  debility  is  in  fact  often  so  marked  that  the  least  exer- 
tion causes  rapid  breathing  and  heart-action  with  exhaustion.  Profuse  sweats 
are  not  unusual.  The  fever  declines  in  from  three  to  seven  days ;  critical 
sweats  or  diarrhoea  may  occur,  the  chest  symptoms  subside,  and  convales- 
cence ensues,  marked  by  a  -strong  tendency  to  recurrence  of  catarrhal  irri- 
tation. 

Pneumonia  is  a  frequent  complication  of  this  type.  It  may  develop  insidi- 
ously while  the  patient  is  in  bed  ;  it  may  occur  at  the  very  onset  of  the  attack  ; 
and  in  many  cases  it  is  induced  by  exposure  even  in  cases  of  apparently  trifling 
character. 

In  the  gastro-intestinal  form  the  sym))toms  may  be  of  moderate  severity, 
consisting  of  nausea  and  occasional  vomiting,  heavily-coated  tongue,  complete 
anorexia,  fulness  and  tenderness  of  the  epigastric  region,  some  distension  of 
the  abdomen,  and  a  tendency  to  looseness  of  the  bowels,  and  fever  not  exceed- 
ing 102J°  F.,  with  headache  and  myalgic  pains,  and  running  a  favorable  course 
of  from  seven  to  ten  days.     But  in  other  cases  the  onset  is  abrupt,  with  the 


COMPLICAriOys   AXD    sequel.^.  189 

violence  of  cholera  morbus,  mul  iiulicatino-  intense  irritation  of  tlie  mucous 
surface,  with  profound  disturbance  of  the  spUmchnic  nerves. 

The  nervous  or  cerebro-spinal  form  may  be  primary,  hut  is  often  developed 
in  the  course  of  cases  ori^^inallv  of  another  tv])c.  The  headache  is  aironi/.inulv 
acute;  sight  and  hearing  are  morbidly  acute;  the  pain  in  the  back  and  legs 
and  the  general  muscular  soreness  arc  intense;  delirium  may  be  marked,  with 
an  increasing  tendency  to  stupor;  rigidity  of  the  muscles  of  the  nucha,  with 
retraction  of  the  head,  may  be  present ;  and  general  convulsittns  may  occur 
both  in  children  and  adults.  The  temperature  may  be  high,  but  in  other  cases 
it  falls  below  normal,  with  slow,  irregular  pulse  and  breathing.  It  can  scarcely 
be  doubted  that  the  more  grave  symptoms  of  this  type  are  due  to  the  develop- 
ment of  a  meningitis. 

In  all  of  these  forms  epistaxis  is  of  occasional  occurrence.  There  are  no 
characteristic  eruptions,  but  herpetic  groups  often  appear  on  the  lips  or  face. 
Urticaria  is  also  common. 

The  identity  of  these  different  types  of  influenza  is  shown  conclusively  by 
the  fact  that  all  may  be  illustrated  in  a  single  family  at  the  same  time,  that 
any  one  may  be  contracted  by  contact  with  a  patient  suffering  with  another 
type,  and  that  the  symptom  of  one  form  becomes  associated  with  the  fully- 
developed  features  of  another  as  the  case  assumes  additional  gravity. 

Complications  and  Sequelae. — The  most  frequent  complications  are  those 
connected  with  the  respiratory  organs.  A  certain  degree  of  bronchial  catarrh 
is  to  be  regarded  as  among  the  usual  symptoms,  but  there  is  a  marked  tendency 
in  most  epidemics  to  the  occurrence  of  severe  bronchitis  of  the  larger  tubes,  or 
even  to  capillary  bronchitis,  associated  in  old  or  feeble  subjects  with  (cdema  of 
the  lungs,  and  attended  with  fever  and  often  with  a  low  form  of  delirium.  In 
all  probabilitv  patches  of  broncho-pneumonia- coexist  in  many  of  these  cases. 
A  fatal  result  from  cardiac  failure  or  from  progressive  cyanosis  is  a])t  to  occur. 

Pneumonia,  both  croupous  and  catarrhal,  is  a  frequent  and  fatal  complica- 
tion. This  was  pre-eminently  so  during  the  recent  ei)idemic.  In  some  cases 
the  attack  begins  as  one  of  severe  infectious  fever,  with  dyspntea  in  excess  of 
any  demonstrable  cause ;  but  in  two  or  three  days  the  ])hysieal  signs  of  pneu- 
monia become  manifest:  cough  may  be  trifling  and  expectoration  almost 
absent,  though  the  pneumonic  area  is  extensive.  It  is  l)y  no  means  only  in 
cases  which  present  severe  bronchitis  tliat  there  is  danger  of  this  compli»a- 
tion  developing.  In  some  epidemics  it  is  so  frequent  as  to  suggest  that  it  is 
induced  by  profound  depression  of  nerve-force,  so  as  to  resendde  the  |.ulmo- 
nary  lesions  developed  after  section  of  the  vagi.  (iuitera>  and  White  have 
suggested  that  in  some  cases  the  Ijronchial  glands  may  be  acutely  enlarged, 
and  the  nervous  tract  about  the  root  of  the  lung  may  !•(•  involved.  Children 
and  aged  and  infirm  sid>jects  are  especially  liable  to  this  com|.licatioii  of  pneu- 
monia. The  readiness  with  which  violent  pnciniiunia  may  be  induced  by 
slight  exposure,  even  in  mild  cases  of  inlliicn/a  in  viirun.iis  adults,  was 
remarkably  shown  dmiii-  the  l;i(e  epidemic.  A  single  instance  will  illustrate 
what  was  of  freqiicnt  occurrence,  though  usually  with  less  violence:    A    yoiing 


1 90  INFL  UENZA . 

man  of  thirtv  years  returned  from  a  hunting-trip  in  fine  physical  condition  to 
his  home,  where  members  of  his  family  had  influenza.  He  promptly  con- 
tracted the  disease  in  so  mild  a  form  that  he  did  not  consult  a  physician  nor 
even  remain  in  his  chamber.  By  the  fourth  day  he  felt  so  much  better  that 
he  insisted  on  walking  about  two  hundred  yards  in  the  raw  evening  air. 
Within  one  hour  he  was  taken  with  severe  chill  ;  the  temperature  was  105°  F. 
bv  the  time  he  was  conveyed  home ;  he  vomited  blood ;  pneumonia  began  in 
the  left  lower  lobe,  involved  the  entire  left  lung,  then  spread  to  the  base  of 
the  right  lung,  was  complicated  with  nephritis,  jaundice,  and  delirium  ;  and  the 
autopsy  showed  that  finally  there  was  but  a  small  area  at  the  right  apex  which 
was  not  consolidated. 

I  secured  statistics  of  35,413  cases  of  influenza  occurring  in  the  practice 
of  272  physicians  in  Philadelphia :  pneumonia  occurred  in  1485,  or  about  4 
per  cent.,  with  a  mortality  of  173,  or  11.65  per  cent.  Dr.  Latta,  chief  medical 
exauiiner  of  the  Pennsylvania  R.  R.  Voluntary  Relief  Department,  kindly 
gave  me  the  statistics  of  influenza  as  affecting  its  members,  who  may  be 
regarded  as  a  carefully  selected  body  of  men.  In  1890  and  1891  there  were 
6680  cases  of  influenza,  showing  that  over  14  per  cent,  of  the  entire  member- 
ship were  so  severely  affected  with  influenza  as  to  confine  them  to  the  house ; 
pneumonia  occurred  in  138  cases,  or  in  2  per  cent.,  with  a  mortality  of  29,  or 
20  per  cent.  The  accompanying  chart  (Fig.  12)  exhibits  the  extraordinary 
prevalence  and  fatality  of  pneumonia  during  this  epidemic.  Undoubtedly  in 
very  many  cases  of  death  reported  as  from  pneumonia  the  disease  was  grippal 
in  nature. 

Many  cases  of  pneumonia  presented  an  extraordinary  feebleness  of  respira- 
tory murmur,  both  before  and  after  the  appearance  of  consolidation.  Typhoid 
delirium  and  a  tendency  to  heart  failure  were  common.  Intense  abdominal 
engorgement  with  jaundice,  and  slight  intestinal  haemorrhage,  were  not  rare. 
Both  hings  were  often  involved  and  the  mortality  was  high.  Alison  of  Bac- 
carat describes  a  focus  of  contagion  which  gave  rise  to  eight  cases  of  pneu- 
monia in  closely  related  families,  and  in  every  case  a  fatal  result  followed. 

Plastic  pleurisy  is  almost  universally  associated,  and  empyema  may  occur, 
as  may  also  purulent  pericarditis,  either  with  or  without  pneumonia.  Abscess 
and  gangrene  of  the  lungs  are  rare  sequels.  Pulmonary  phthisis  must  be 
noted  among  the  sequels  also,  and  when  influenza  attacks  those  already 
affected  with  plithisis,  the  mortality  is  high  and  the  course  of  the  organic 
disease  is  greatly  hastened  in  those  who  survive.  The  same  statement  must 
be  made,  in  identical  terms,  in  regard  to  Bright's  disease. 

The  occurrence  of  severe  gastro-intestinal  catarrh  as  a  complication,  with 
vomiting  and  purging,  has  already  been  mentioned,  together  with  the  much, 
more  rare  haemorrhage  from  the  stomach  or  bowel.  After  the  subsidence  of 
tiie  acute  symptoms  a  chronic  gastro-intestinal  catarrh  is  apt  to  persist,  with 
grave  impairment  of  nutrition,  and  to  prove  rebellious  to  treatment. 

Cerebro-spinal  meningitis  undoubtedly  occurs  as  an  occasional  complication. 
In  some  instances  the  onset  is  indistinguishable  from  cerebro-spinal  fever  save 


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192  INFL  UENZA . 

by  the  absence  of  petechial  eruption  ;  and  it  is  important  to  bear  in  mind  that 
not  a  few  epidemics  of  influenza  have  been  regarded  as  of  that  nature  by  ex- 
perienced observers.  The  cases  either  run  an  acute  course  with  intense  head- 
ache, delirium,  stupor,  general  convulsions,  extreme  retraction  of  the  head, 
and  terminate  fatally,  or  the  symptoms  are  less  violent  and  the  case  goes  on 
to  gradual  recovery  or  to  the  development  of  all  the  symptoms  of  exudation 
with  fatal  pressure.  Several  cases  of  abscess  of  the  brain  were  reported 
in  the  late  epidemic  by  Bristowe,  and  one  case  occurred  in  the  P.  R.  R. 
series. 

Persistent  headache,  insomnia,  and  neuralgia  are  common  sequels.  Otitis 
media  was  reported  in  a  number  of  cases,  and  affection  of  the  optic  nerve  like- 
wise. Melancholia,  impairment  of  mental  power,  and  even  mania  are  among 
the  sequels.  In  no  less  than  18  cases  in  the  P.  R.  R.  series  did  it  become 
necessary  to  confine  the  patients  to  insane  asylums:  5  of  these  cases  have 
proved  fatal.  The  dejection  of  spirits  which  often  attends  convalescence  is 
remarkable,  and  has  not  failed  to  attract  attention  in  many  epidemics. 

Perineuritis  is  one  of  the  most  frequent  complications  and  sequels.  Much 
of  the  suffering  in  the  disease  may  be  referred  to  this  cause.  The  nerves  of 
special  sense  may  be  involved,  and  it  is  not  impossible  that  implication  of 
branches  of  the  pneumogastric  may  explain  some  of  the  grave  pulmonary 
and  gastric  conditions  which  arise.  Persistent  peripheral  neuritis,  muscular 
atrophy,  and  partial  palsies  have  been  exceptionally  frequent  since  the  last 
widespread  outbreak  of  influenza. 

Enlargement  of  the  lymph-glands,  and  especially  those  of  the  cervical 
chains,  is  not  infrequent  in  some  epidemics  as  a  sequel.  It  may  prove  per- 
sistent and  troublesome,  and  occasionally  ends  in  suppuration. 

As  already  stated,  an  attack  of  influenza  affords  but  little  protection  against 
subsequent  attacks.  Several  well-marked  attacks  have  been  suffered  by  many 
individuals  during  the  past  two  years.  Relapses  also  are  not  infrequent.  In 
the  6680  cases  of  the  P.  R.  R.  series  they  occurred  in  762  instances,  or  in  over 
11  per  cent. 

Diagnosis. — During  an  epidemic  of  influenza  the  entire  mortality  of  the 
community  is  greatly  increased.  At  the  height  of  the  recent  epidemic  the  num- 
ber of  deaths  in  many  cities  was  quite  double  that  of  the  corresponding  period 
of  i)receding  years.  In  Philadelphia  the  total  mortality  for  the  month  of  Jan- 
uary, 1889,  was  1862,  and  for  December,  1889,  was  1488;  in  January,  1890, 
the  epidemic  of  influenza  Avas  at  its  height,  and  the  mortality  rose  at  a  bound 
to  3044,  of  which  number  only  116  were  reported  as  influenza.  It  is  evident 
that  this  sudden  increase  in  the  number  of  deaths  is  due  in  large  part  to  the 
serious  mortality  of  influenza  itself  when  complicated,  as  with  bronchitis  or 
pneumonia.  But,  in  addition,  many  chronic  affections,  such  as  Bright's  dis- 
ease, phthisis,  heart  disease,  are  awakened  to  rapidly  fatal  activity  by  tiie 
influence  of  the  grippal  poison.  While,  therefore,  there  is  a  tendency  dur- 
ing the  prevalence  of  all  e])idemic  diseases  to  err  in  regarding  almost  every 
case  of  illness  as  belonging  to  the  prevailing  malady,  it  is  doubtful  whether. 


PROGXOSIS;    MORTALITY.  193 

in  severe  outbreaks  of  influenza,  the  extraordinary  ditTiision  of  the  infection 
is  even  suflKciently  appreciated.  On  the  other  hand,  it  is  no  less  true  that 
sporadic  cases  of  influenza  are  liable  to  have  their  true  nature  overlooked, 
and  to  be  regarded  as  idiopathic  catarrhal  fever  or  to  be  confounded  with 
other  infectious  diseases.  Not  until  the  bacterioloo;ical  diagnosis  of  influenza 
conies  to  be  widely  practisetl  will  the  protean  manifestations  of  this  disease  be 
fully  determined. 

Cases  of  the  ordinary  thoracic  type  should  be  readily  recognized  by  the 
sudden  onset,  the  absence  of  the  usual  causes  of  bronchitis,  the  ciiaracter  of  the 
cough,  the  pains  in  the  head,  back,  and  limbs,  the  prostration  and  sense  of  ill- 
ness out  of  seeming  proportion  with  the  degree  of  fever  or  the  physical  signs 
of  pulmonary  trouble. 

The  gastro-intestinal  type  is  more  apt  to  be  mistaken  either  for  acute  catar- 
rhal gastritis,  for  simple  continued  fever,  or  even  for  typhoid  fever.  The 
absence  of  the  usual  causes,  the  greater  degree  of  prostration,  and  the  charac- 
teristic pains  distinguish  it  from  the  first,  while  typhoid  fever  is  known  by  the 
more  slow  onset  and  gradual  development,  by  the  greater  enlargement  <»f  the 
spleen,  the  appearence  of  the  stools,  and  the  characteristic  eruption,  although  in 
influenza  abdominal  distension,  diarrha?a,  epistaxis,  bronchial  catarrh,  fever, 
headache,  and  delirium  may  occur.  During  an  epidemic  of  influenza  many 
cases  which  are  regarded  as  ephemeral  or  simple  continued  fever  are  doubtless 
grip])al  in  nature. 

Cases  complicated  with  the  early  development  of  pneumonia  are  peculiarly 
liable  to  have  their  true  character  overlooked. 

Allusion  has  been  made  in  the  article  on  Cerebro-spinal  Fever  to  the 
resemblance  between  that  disease  and  the  cerebro-spinal  type  of  influenza.  It 
appears  that  from  the  earliest  period  these  two  diseases  have  often  jirevaikxi 
coincidently  or  in  close  sequence.  When  the  meningitic  symptoms  ensue  in  a 
case  which  has  begun  as  of  the  catarrhal  type,  there  is  less  danger  of  over- 
looking their  grippal  nature.  But  when,  as  happens  with  considerable  fre- 
quencv  during  certain  epidemics,  patients  are  seized  with  intense  pain  in  the 
head,  back,  and  limbs,  slight  fever,  rapidl}*  developing  delirium  and  stupor, 
muscular  rigidity,  and  possibly  retraction  of  the  head,  or  even  general  convul- 
sions, herpetic  and  possibly  petechial  eru|)ti<)n,  and  when  at  the  autopsy  the 
lesions  of  cerebro-spinal  meningitis  are  discovered,  it  is  evident  that  careful 
bacteriolo<rical  work  is  needed  to  decide  as  to  the  exact  character  of  the  infee- 
tion.  The  cases  recorded  by  H.  B.  Allyn  in  1892  are  extremely  interesting 
as  illustrations  of  the  above. 

In  the  article  on  Dengue  reference  is  made  to  the  diagnosis  of  this  pecu- 
liar epidemic  disease  from  influenza,  with  which  it  has  points  of  strong 
analogv. 

Prognosis;  Mortality. — Apart  from  serious  coiiiplieatious,  the  nioiiality 

of  the  ordinary  catarrhal  types  of  influenza  is  extremely  small,  certaiidy  less 

than  i  of  1    per  cent.     In  6080  carefully  observed  cases  in  the    P.    \l.    It. 

series  the  total  mortality  was  94,  or  about  1.1  i.er  cent,  a  little  less  than  onc- 

VoL.  I.— v. 


1 94  I  NFL  UENZA . 

third  of  which  was  from  uncomplicated  grippe.  The  number  of  deaths  in  the 
35,413  cases  of  influenza  collected  by  myself  was  257,  or  0.72  per  cent.,  and 
of  these  84,  or  about  J  of  1  per  cent,  of  the  whole  number,  were  from  uncom- 
plicated grippe. 

The  liability  to  severe  complications  is,  however,  so  distinctive  a  feature  of 
many  epidemics  of  influenza  that  the  prognosis  should  never  be  regarded  as 
trifling.  The  development  of  intense  bronchitis,  pneumonia,  nephritis,  or 
meningitis  at  once  renders  the  case  very  dangerous.  In  some  epidemics  the 
mortality  is  very  large,  owing  especially  to  the  extreme  prevalence  of  pneu- 
monia or  of  meningitis. 

The  prognosis  is  much  more  serious  in  the  aged  or  in  persons  of  infirm 
health.  When  patients  with  phthisis,  paralysis,  heart  disease,  or  organic  kid- 
ney disease  are  attacked  with  influenza,  the  danger  is  always  considerable. 
If  they  recover  from  the  attack,  there  is  great  reason  to  dread  subsequent 
aggravation  of  their  organic  trouble. 

Treatment. — No  reliable  means  of  prevention  are  known.  Althaus  urges 
Avholesale  protective  revaccination  of  the  population  with  animal  lymph.  The 
evidence  on  which  this  startling  proposition  is  based  seems  wholly  inadequate. 
One  of  the  worst  cases  of  influenza  I  ever  saw  followed  by  recovery  occurred 
in  a  child  nine  months  of  age,  who  had  just  passed  through  a  typically  suc- 
cessful vaccination  with  animal  lymph.  Fatigue  and  excesses  of  all  kinds, 
and  especially  in  venery,  predispose  to  the  contraction  of  influenza.  Any 
exposure  which  induces  catarrh  during  the  prevalence  of  influenza  almost 
ensures  the  reception  of  the  iufection.  Great  care  in  clothing,  in  the  avoid- 
ance of  damp,  of  draughts,  and  of  any  sudden  check  of  perspiration,  should  be 
observed  during  the  epidemic  by  all  persons,  and  especially  by  those  of  feeble 
vitality  or  who  are  affected  by  any  organic  disease. 

Rest  in  bed  must  be  insisted  on  from  the  onset  until  convalescence  is  estab- 
lished. Most  of  the  mortality  may  be  traced  to  a  neglect  of  this  cardinal 
rule.  Unusual  care  should  be  used  to  avoid  draughts  or  sudden  changes  of 
temperature  in  the  sick-room.  In  addition  to  the  avoidance  of  complications 
by  strict  nursing,  the  indications  at-e  to  support  the  system,  to  relieve  suffering, 
to  secure  sleep,  to  allay  cough,  and  to  control  fever. 

Purgatives  should  be  avoided.  If  the  tongue  is  heavily  coated,  the  stom- 
ach embarrassed,  and  the  bowels  constipated,  a  few  fractional  doses  of  calomel 
or  of  a  mild  saline  may  be  given  ;  but,  as  a  rule,  any  laxative  effect  is  best 
secured  by  enema  or  suppository.  The  diet  may  be  as  supporting  as  the  diges- 
tion will  admit.  It  is  not  well  to  restrict  the  patient  to  liquids  save  in  cases 
of  the  gastro-intestinal  type. 

The  fever  is  not  often  high  enough  to  demand  vigorous  antipyretic  treat- 
ment. Hydrotherapy  should  be  used  with  extreme  caution,  on  account  of  the 
wholly  exceptional  tendency  to  catarrhal  and  inflammatory  complications. 
Phenacetin  in  moderate  doses,  gr.  iij  to  v,  repeated  two  or  three  times  in 
twenty-four  hours,  reduces  temperature,  relieves  suffering,  and  tends  to  secure 
sleep.     It  is  less  likely  to  cause  undue  depression  and  relaxation  of  the  system 


TREATMENT.  195 

tlian  antipyrine,  though  all  drugs  of  this  chvss  must  be  used  with  great  caution 
in  influenza.  Small  doses  of  antipyrine,  gr.  iij,  combined  with  quinine  or  s(xli- 
um  salicylate,  may  also  be  given  two  or  three  times  in  twenty-four  hours,  but 
require  watching  as  to  their  effect.  Quinine  in  tonic  dt)ses  is  indeed  indicated 
in  most  cases.  It  may  be  combined  advantageously  with  opium,  and  the  fol- 
lowing formula  is  often  useful  as  meeting  several  indications : 

^.  Quininse  sulph.,  3j  ; 

Pulv.  digitalis,  gr,  xx  ; 

*  Pulv.  scillae,  gr.  xx ; 

Ext.  opii,  gr.  v  ; 

Ext.  glycyrrhizse,  q.  s. 
Misce  et  ft.  pil.  xxx. 
Sig.  A  pill  three  or  four  times  daily. 

The  condition  of  the  stomach  demands  careful  attention  :  if  there  be  marked 
irritability,  the  diet  must  be  restricted  rigidly,  and  no  remedies  given  internally 
save  those  which  tend  to  soothe  it,  such  as  small  doses  of  the  tincture  of  aconite- 
root  as  a  febrifuge,  and  bismuth  subnitrate  or  cerium  oxalate  or  silver  nitrate, 
witli  minute  doses  of  cocaine,  for  local  action  on  the  mucous  membrane. 

The  severe  headache  may  be,  especially  if  associated  with  high  tcmjiernture, 
treated  by  cold  applications  to  the  head  and  small  doses  of  phenacetin.  \lni  it 
is  so  often  accompanied  by  insomnia  that  codeine,  or  even  morphine,  may 
be  required.  Sul phonal  may  prove  adequate  to  afford  sleep  when  pain  is 
not  prominent. 

The  pulmonary  complications  require  prompt  attention.  Mild  cdunter- 
irritation  should  be  used,  and  the  chest  be  enveloped  in  a  raw-cotton  jacket. 
Most  exj)ectorant  remedies  are  contraindicated  by  their  tendency  to  disorder 
the  stomach  or  to  relax  and  depress  the  system.  Upon  the  whole,  strychnine 
in  full  doses  is  the  most  important  remedy  against  these  complications — a  fact 
which  suj)ports  the  view  that  depressed  pneumogastric  power  has  mucii  to  do 
with  their  production.     The  follow^ing  is  often  valuable: 

'Sf.  Morphinse  sulph,,  gr.  j  ; 

QuininaB  sulj)h.,  gr.  xxxvj  ; 

Strychninse  sulj)h.,  gr.  ss  ; 

Acid,  phosphoric,  diluti,  f.^iij  ; 

Glyccrinaj,  ^.^v ; 

Aquse,  q.  s.  ad  f.^iij.— AI, 
Sig.  A  teaspoonful  in  water  from  three  to  six  times  daily. 

Or  in  very  severe  cases  with  tendency  to  cardiac  and  n's|)iraf()ry  failure  hypo- 
dermic injections  of  small  doses  of  morphine,  gr.  ^^,  with  large  (loses  of 
strychnine,  gr.  ^^j,  may  be  used  several  fiincs  daily. 


196  INFLUENZA. 

Aromatic  spirit  of  ammonia,  or  carbonate  of  ammonium,  or  oil  of  turpentine 
in  emulsion  if  acceptable  to  the  stomach,  may  be  given  internally.  A  certain 
measure  of  relief  to  the  severe  pains  in  the  back,  chest,  and  limbs  is  also 
afforded  by  external  applications,  such  as  St.  John  Long's  liniment,  or  com- 
pound chloroform  liniment  containing  aconite  and  ammonia,  or  veratria  oint- 
ment, or  the  following  applied  over  areas  of  persistent  pain  : 

"Sf.  Tr.  aconiti  radicis, 

Chloroformi,  da.  fsj  ; 

Tr.  iodini,  f^vj. — M." 

Sig.  Apply  locally. 

The  only  condition  in  which  depletion  is  to  be  thought  of  in  influenza  is 
when  severe  cerebro-spinal  symptoms  appear  abruptly.  In  vigorous  adults 
I  have  then  used  moderate  venesection  with  immediate  and  lasting  advantage. 
The  fear  that  meningitis  will  be  established  is  the  controlling  motive.  If  this 
measure  seems  too  severe,  local  depletion  by  wet  or  dry  cups  or  leeches  may 
be  substituted.  If  the  symptoms  are  less  urgent,  cold  applications  to  the 
head,  hot  footbatlis,  or  sinapisms  to  the  back  and  limbs  may  suffice  in  con- 
nection with  suitable  internal  remedies. 

Convalescence  demands  the  closest  supervision.  All  details  of  personal 
hygiene  must  be  insisted  upon.  Nutritious  diet,  avoidance  of  bodily  or  men- 
tal exertion,  careful  avoidance  of  undue  exposure,  the  continued  use  of  tonic 
remedies,  and,  if  possible,  suitable  change  of  air,  will  promote  more  full  and 
rapid  return  to  health.  The  depressing  and  enfeebling  influence  of  the  dis- 
ease will,  however,  be  often  found  to  be  strangely  persistent.  It  is  of  especial 
importance  that  those  who  are  still  suffering  from  this  depression  should  not 
be  exposed  to  the  danger  of  reinfection,  as  fresh  attacks  contracted  under  such 
circumstances  are  apt  to  prove  very  serious. 


DENGUE. 

By  WILLIAM   PEPPER. 


Definition. — Dengue  is  an  acute  specific  disease,  occurring  in  epidemics 
which  are  chiefly  confined  to  tropical  and  subtropical  latitudes,  without  defi- 
nite anatomical  lesions,  and  characterized  clinically  by  two  paroxysms  of  fever 
with  a  ni^arked  remission,  severe  pains  in  the  muscles  and  joints,  anomalous 
eruptions,  and  a  very  low  rate  of  mortality. 

Synonyms. — The  number  and  grotesque  variety  of  the  names  applied  to 
this  disease  attest  its  peculiar  and  variable  character.  .Many  refer  to  the  })ains, 
as  breakbone  and  eruptive  rheumatic  fever;  othei's  to  the  eruptions,  which  are 
prominent  in  some  epidemics;  others,  again,  are  popular  terms  descri)>tive  of 
special  symptoms.  The  name  dengue,  equivalent  to  "coquettish  "  in  Spanish, 
seems  to  have  been  given  on  account  of  the  stiff,  affected  gait  of  those  recover- 
ing from  the  disease. 

Etiolog-y. — Dengue  is  essentially  a  disease  of  warm  latitudes.  It  was 
first  recognized  in  1779  in  Java  by  David  Brylon,  who  called  it  articular 
fever.  The  earliest  accurate  accounts  are  of  epidemics  in  India  in  1824  and 
later.  According  to  Matas,  the  conclusion  of  epidemiologists  is  that  it  was 
originally  an  Asiatic  tropical  infection,  starting  perhaps  in  India.  It  is 
known  to  prevail  sporadically  there,  and  also  in  Africa,  and  ])rol)ably  also  in 
our  Gulf  States.  Of  European  countries  Spain  alone  has  suffered.  Frequent 
epidemics  have  occurred  in  South  American  countries,  in  the  West  Indies,  and 
in  the  Southern  United  States.  Rare  outbreaks  have  been  noted  in  Philadeljihia, 
New  York,  and  even  in  Boston.  The  usual  limits  of  its  epidemics  are  32°  N. 
and  22°  S.  lat.  The  summer  seasons  appear  to  favor  its  occurrence.  Neither 
race,  age,  sex,  nor  social  condition  exerts  any  influence. 

There  can  be  little  doubt  as  to  its  contagiousness.  Its  epidemics  spread 
with  extreme  rapidity  along  the  routes  of  travel.  It  is  probable  the  poison 
may  be  carried  by  fomites.  McLaughlin  of  Texas  has  found  in  the  blood  of 
patients  with  dengue  a  micrococcus  which  he  believes  to  be  characteristic  of  (he 
disease,  but  Osier  holds  it  to  be  still  sub  jiuJicc. 

The  susceptibility  to  the  infection  of  dengue  is  almost  uuivcr<:il.  In  the 
great  Texas  epidemic  of  1885,  McLaughlin  estimates  that  in  the  city  of 
Austin  alone,  out  of  a  population  of  22,000,  no  less  than  10,000  j)ersons 
were  attacked  in  the  course  of  a  few  months.  The  occurrence  of  an  analogous 
disease  among  domestic  animals  simultaneously  with  (he  prevalence  of  dengue 
has  been  noted  several  times. 

The  frequency  with  which  relapses  and  recurrent  attacks  occur  wouM  swni 

187 


198  DENGUE. 

to  diiFer  in  different  epidemics ;  but  on  the  whole  they  are  much  more  frequent 
than  in  most  infectious  diseases.  In  some  epidemics  relapses  have  occurred  as 
often  as  in  15  per  cent,  of  all  cases.  It  has  even  been  claimed  by  a  few  that 
an  attack  of  the  disease  predisposes  to  a  subsequent  attack. 

Morbid  Anatomy. — There  are  no  lesions  known  to  pertain  to  the  disease 
itself.  Death  scarcely  ever  occurs,  except  from  complications,  and  even  then 
is  of  extreme  rarity. 

Symptomatology.  — The  onset  of  dengue  is  usually  abrupt,  after  a  period 
of  incubation  of  about  four  days'  duration,  and  without  prodromes.  There  is 
a  chill,  which  in  young  children  may  be  replaced  by  a  convulsion.  The  tem- 
perature rises  quite  rapidly,  and  at  the  close  of  the  first  or  second  day  usually 
reaches  its  height,  from  102°  to  106°  F.,  according  to  the  severity  of  the 
attack.  Intense  headache,  backache,  and  pain  in  the  joints  ensue  quickly. 
The  muscles  also  are  painful  and  sore.  There  is  a  sense  of  extreme  depression 
and  prostration.  Delirium  and  hebetude  are  slight,  if  at  all  present,  and  the 
patients  are  usually  keenly  conscious  of  their  intolerable  sufferings.  The 
pulse  and  respiration  are  rapid.  The  tongue  is  moist  and  yellow-coated ; 
appetite  is  lost ;  nausea  is  moderate ;  the  bowels  are  quiet.  The  urine  is 
febrile,  but  scarcely  ever  albuminous.  A  transitory  erythematous  rash  appears 
in  a  varying  proportion  of  cases  in  different  epidemics.  The  joints  are  often 
painful,  stiffened,  and  even  red  and  swollen. 

In  some  cases  the  symptoms  assume  a  marked  gastro-intestinal  type  and 
severe  vomiting  and  purging  occur.  More  rarely  cerebral  symptoms  may  be 
prominent,  and  increasing  stupor  and  evidences  of  meningitis  ensue.  Doubt- 
less these  nervous  symptoms  are  often  due  to  hyperpyrexia  :  Holliday  reports 
a  fatal  case  in  which  the  temperature  rose  to  109|°  F.  Epistaxis  may  occur, 
and  so  may  haemorrhage  from  the  stomach  or  bowels. 

The  primary  febrile  paroxysm  lasts  from  three  to  five  days,  and  is  termi- 
nated by  a  critical  fall  with  sweating  or  diarrhoea.  The  temperature  may 
become  subnormal  and  the  pulse  abnormally  sIoav,  but  more  commonly  it  is 
only  a  remission.  The  symptoms  are  greatly  relieved,  but  the  patient  still 
feels  stiff'  and  Aveak.  At  this  time  or  with  the  return  of  fever,  which  occurs 
after  an  interval  of  two  or  three  days,  a  second  eruption  appears,  with  vary- 
ing frequency  in  different  epidemics.  It  is  not  characteristic,  but  may  resem- 
ble urticaria,  herpes,  lichen,  or  erythema.  The  second  paroxysm  of  fever  is 
usually  mild  and  short.  The  pains,  restlessness,  and  anorexia  return.  Defer- 
vescence occurs  again  after  two  or  three  days,  and  subnormal  temperature  and 
pulse  are  noted  not  rarely.  The  eruptions  fade  rapidly,  and  desquamation 
commonly  follows. 

The  entire  duration  of  an  ordinary  case  is  from  seven  to  nine  days.  Con- 
valescence may  be  prompt,  but  is  apt  to  be  slow  and  protracted,  and  to  be 
attended  with  a  singular  degree  of  mental  depression  and  loss  of  energy  or 
actual  debility. 

As  already  stated,  the  disease  terminates  habitually  in  recovery  in  spite  of 
the  painful  or  alarming  symptoms. 


COMPLICA  TIOXS   A  ND    SEQ  UEL.E.—  TREA  TMEST.  1 1»9 

Complications  and  Sequelae. — The  oc-easional  occurrence  of  severe 
nervous  syniptoms  has  been  mentioned.  The  character  and  favorable  coui*se 
of  these  indicate  their  dependence  on  the  high  fever  as  a  rule.  Any  lesion, 
such  as  meningitis,  which  is  mentioned  by  some  observer's,  must  be  extremely 
rare.  Insomnia  may  persist  for  some  time  after  the  disease,  but  more  com- 
monly the  only  nervous  sequels  are  neuralgic  pains  and  markeil  prostration 
and  depression  of  spirits,  Avhich  may  last  for  weeks,  especially  among  the 
weak  and  infirm.  Rush  states  in  his  report  of  an  epidemic  of  dengue  in 
Philadelphia  in  1780  that  a  young  lady  remarked  it  might  be  called  bre<ik- 
heart  instead  of  break-bone  fever ;  and  this  remark  might  be  applied  with 
equal  fitness  to  influenza.  Severe  catarrhal  inflammation  of  the  respiratory  or 
gastro-intestinal  mucous  membranes,  catarrhal  jaundice,  or  hiemorrhages  may 
occur  occasionally.  Enlargement  of  the  lymphatic  glands  in  various  i>arts  of 
the  body  is  not  rare,  and  may  prove  obstinate :  in  some  epidemics  crops  of 
furuncles  and  superficial  abscesses  have  been  noted. 

Diag-nosis. — Sporadic  cases  of  dengue  may  readily  be  mistaken  for  mild 
rheumatic  fever,  but  the  presence  of  eruptions,  the  absence  of  acid  sweats,  the 
peculiar  course  of  the  fever,  and  the  absence  of  cardiac  complication  serve  to 
distinguish  it.     The  disease  to  which  it  presents  most  resemblance,  both  in  its 
sporadic  and  epidemic  forms,  would  seem  to  be  influenza.     The  accounts  of 
some  epidemics  of  dengue  leave  doubt  as  to  whether  they  may  not  have  been 
outbreaks  of  mild  influenza  in  a  warm  latitude.     The  diseases  rescrnl)lc  each 
other  in  the  rapidity  of  development   in  great  communities  and  over  large 
areas ;  in  the  large  proportion  of  the  population  afl'ectcd  ;  in  the  frequency  of 
relapses  and  the  liability  to  successive  attacks;  in  the  disproportion  between 
the  apparent  gravity  of  the  symptoms  and  the  very  small   mortality  of  the 
uncomplicated  disease ;  in  the  sudden  onset,  the  peculiar  severity  and  charac- 
ter of  the  pains,  the  great  mental  and  bodily  prostration.     But  in  influenza 
the  only  eruption  frequently  present  is  herpes;  there  is  no  afl'cction  of  the 
joints  (although  :Matas  states  that  in  dengue  also  true  evidences  of  arthritis, 
such  as  redness  and  swelling,  are  exceptional);  the  remission  and  recurrence  in 
the  course  of  the  fever  are  not  present ;  there  is  a  far  greater  liability  to  seri- 
ous complications ;  and  the  disease  is  wholly  indei>endcnt  of  geographical  re- 
strictions.     Bacteriological  research  must,  however,  complete  the  separation 

of  the  two  diseases. 

When  yellow  fever  and  dengue  prevail  simultaneously,  care  is  recjuired  to 
avoid  confounding  the  latter  with  mild  and  imi)er('(rt  cases  of  the  more  grave 
malady.  The  initial  eruption  may  lead  dengue  to  be  mistuken  also  for  some 
one  of  the  eruptive  fevers. 

The  prognosis  is,  as  already  stated,  almost  invariably  favorable.  In 
American  epidemics  it  has  been  rare  for  even  a  single  death  to  oeeiir.  Mafas 
quotes  a  statement  that  in  Madras  dengue  was  sometimes  fatal  in  adults  from 
pericarditis  and  in  children  from  wmvulsions,  20  deaths  occurring  out  of  .'1017 
cases  collected  by  one  observer. 

Treatment.— The  nniformlv  lavorable  and  selC-liniited  course  of  .l.ngue 


200  DENG  UE. 

calls  for  merely  symptomatic  treatment.  Strict  rest  in  bed  should  be  insisted 
upon,  and  rigid  attention  should  be  paid  to  all  details  of  nursing  and  hygiene 
till  convalescence  is  established.  A  mild  laxative  may  be  administered  at  the 
outset. 

The  fever  may  be  high  enough  to  call  for  small  doses  of  phenacetin  or 
antipyrine,  which  should  also  be  very  useful  in  allaying  the  peculiar  arthritic 
and  myalgic  pains.  Quinine  or  salicylate  of  sodium  may  also  be  used.  Hydro- 
therapy is  rarely  indicated,  but  should  be  used  if  the  pyrexia  is  high  and 
accompanied  with  severe  nervous  symptoms.  The  bromides  and  codeine  or 
morphine  are  often  required  to  secure  sleep  and  relieve  suffering. 

Convalescence  demands  a  continuance  of  careful  regulation  of  diet  and 
hygiene.  Tonics  and  nutrients  should  be  given  to  improve  appetite  and  over- 
come the  persistent  debility.  If  myalgic  or  arthritic  pains  continue,  potassium 
iodide  or  sodium  salicylate  will  be  found  useful.  A  change  of  residence  may 
be  required  to  promote  complete  restoration  of  health. 


MILIARY  FEVER. 

By  WILLIAM  PEPPER. 


Definition. — An  acute,  infectious,  and  at  times  epidemic  disease,  character- 
ized by  a  sudden  onset,  with  i)rofuse  sweating,  sense  of  oppression  in  the  epi- 
gastric region,  and  the  appearance  of  a  papulo-vesicular  exanthem. 

Synonyms. — Sweating  sickness  ;  Schweissfriesel ;  Suette  miliare  ;  Suette 
des  Picards;  Sudor  anglicus. 

History. — In  August,  1486,  there  broke  out  in  the  army  of  Henry  VII., 
after  its  return  from  the  battle  of  Bosworth  Field,  an  acute,  virulent,  infectious, 
and  hio-hlv  dangerous  malady  that  soon  spread  throuirhout  Eny;land  and  ratred 
until  November  of  the  same  year.  In  1507  the  disease  again  became  epidemic, 
but  was  confined  to  England.  In  May,  1529,  London  was  again  attacked, 
but  on  this  occasion  the  continent  of  Europe  was  also  affected.  In  1551 
another  epidemic  occurred  in  England,  being  confined  by  the  boundaries  of 
that  country.  In  1718  a  disease  resembling  in  most  of  its  essential  features 
these  earlier  epidemics  appeared  in  l^icardy,  and  from  that  point  spread  to 
other  parts  of  France.  Hirsch  has  tabulated  194  epidemics  of  this  '*  miliary 
fever"  that  occurred  between  the  years  1718  and  1874.  In  various  parts  of 
Italy  and  Germany  also  small  epidemics  have  been  described.  In  1887  there 
was  quite  a  severe  epidemic  in  France.  Tiie  disease  is  practically  never  seen 
now  save  in  the  north-eastern  provinces  of  France  and  in  a  small  portion  of 
Italy. 

Etiology. — Regarding  the  auxiliary  causes  of  the  earlier  epidemics  of 
"sweating  sickness"  but  little  is  known.  There  are,  however,  a  few  facts 
in  relation  to  the  later  outbreaks  of  what  has  been  most  generally  called 
"miliary  fever"  that  show,  at  least  in  the  majority  of  epidemics,  some 
uniformity.  Most  of  the  epidemics  have  occurred  in  spring  and  summer; 
the  disease  usually  is  most  prevalent  in  low-lying  and  (lam|)  areas,  but  has 
been  observed  at  higher  elevations  witii  a  porous,  dry  soil  ;  women  are  more 
subject  to  attack  than  are  men,  and  the  middle  period  of  life  liirnishes  the 
greatest  number  of  cases ;  social  condition  as  to  habits  of  life  inHuciice  the 
liability  to  the  disease  to  no  appreciiible  extent.  The  disease  is  not  c(.ntagious, 
and  is  not  particularly  prevalent  in  institutions,  barracks,  etc.,  when-  people 
are  congregated  in   large  numbers.     No   iinincdiatc  exciting  cause  has  ever 

been  discovered. 

A  curious  relation  between  epidemics  of  this  disease  and  of  A^i.ili.-  chdera 


JOl 


202  MILIARY  FEVER. 

has  been  noted,  the  diseases  interchangeably  following  each  other  or  the  two 
diseases  occurring  at  the  same  time. 

Symptomatolog-y. — After  a  brief  prodromal  period  of  malaise,  weakness, 
and  iieadache  the  patient  is  attacked,  usually  in  the  night,  with  profuse  sweat- 
ing, fever,  and  a  sense  of  oppression  referred  to  the  epigastric  region.  The 
pulse  is  rapid,  there  is  elevation  of  temperature  that  is  rarely  excessive,  and 
there  is  found  to  be  marked  tenderness  over  the  upper  portion  of  the  abdo- 
men. After  a  period  of  three  or  four  days,  in  some  cases  later,  there  appears 
a  characteristic  eruption,  with  temporary  increase  in  all  of  the  symptoms  pre- 
viously observed.  The  exanthem  consists  of  small  reddish  spots  of  irregular 
contour,  but  of  a  generally  round  form,  varying  in  diameter  from  -^^  to  y^ 
of  an  inch.  The  lesions  are  either  closely  aggregated  or  confluent.  In  the 
centre  of  each  spot  there  appears,  after  a  few  hours,  a  small  vesicle,  which 
graduallv  enlarges  to  the  size  of  a  millet-seed  or  pea.  The  clear  contents 
of  the  vesicles  soon  become  opaque,  owing  to  a  purulent  transformation,  and 
then  after  two  or  three  days  dry  into  crusts  which  are  cast  off  as  scales. 

While  the  skin  is  the  usual  site  of  the  eruption,  it  may  also  be  found  upon 
the  nasal,  oral,  and  conjunctival  mucous  membrane.  The  first  appearance  of 
the  eruption  is  generally  upon  the  neck  and  chest ;  after  which  it  is  seen  upon 
the  back  and  extremities.  More  rarely  the  scalp  and  abdomen  may  be  the 
seat  of  the  exanthem. 

From  mild  cases,  wherein  almost  the  only  prominent  symptom  is  the  occur- 
rence of  frequent  and  profuse  sweatings,  the  disease  varies  in  severity  to  fatal 
cases  with  most  severe  symptoms  and  intense  anguish.  In  addition  to  the 
symptoms  that  have  been  mentioned  there  may  be  insomnia,  vertigo,  cephalal- 
gia, complete  anorexia,  thirst,  nausea,  and  marked  constipation.  The  sense  of 
oppression  at  the  epigastrium  may  in  grave  cases  become  so  intense  that  the 
patient  tosses  from  side  to  side,  clutching  at  the  bed-clothes  in  order  to  obtain 
relief;  indeed,  death  from  apnoea  has  been  stated  to  occur.  During  the  sweat- 
ing stage  convulsions  may  occur,  sudden  and  fatal  collapse  may  end  the  scene 
abruptly,  or  the  patient  may  fall  into  a  typhoid  condition.  Convalescence  is 
prolonged. 

Morbid  Anatomy. — No  characteristic  lesions  are  found.  Decomposition 
is  said  to  occur  rapidly,  and  the  blood  is  thin  and  dark  in  color.  In  some 
cases  oedema  of  the  meninges  of  the  brain  has  been  found.  In  most  cases 
the  linigs  are  found  to  be  congested  and  the  heart  soft;  the  pericardium  the 
seat  of  ecchyraoses ;  the  mucous  membrane  of  the  alimentary  tract  congested  ; 
the  liver  full  of  blood  ;  the  spleen  enlarged,  soft,  and  friable.  Some  observers 
claim  that  they  have  found  upon  the  mucous  membrane  of  the  intestine  vesi- 
cles similar  to  those  upon  the  skin. 

Diagnosis. — In  time  of  e|)idemics  this  should  present  no  special  difficulty. 
The  only  diseases  with  which  miliary  fever  would  be  apt  to  be  confounded  are 
acute  rheumatic  fever,  measles,  and  malarial  infection.  The  absence  of  local- 
ized articular  pains,  the  peculiar  sense  of  oppression  in  the  epigastric  region, 
and  the  appearance  of  the  eruption  distinguish  it  from  the  first  of  these.     In 


PROOyOSIS.—TREA  TMEXT.  203  ^ 

measles  the  prodromal  catarrhal  symptoms,  the  absence  of  vesiculation  in  the 
centre  of  the  eruption,  and  the  distribution  of  the  latter  would  prevent  a  mis- 
take in  diagnosis,  even  without  the  absence  of  profuse  sweating,  From  inter- 
mittent fever  this  disease  would  be  distintruished  bv  the  absence  of  marked 
rigor,  the  lack  of  periodicity,  and  the  failure  to  respond  to  specific  antimala- 
rial treatment,  while  the  discovery  of  Laveran's  micro-organisms  in  the  blood 
would  positively  announce  the  presence  of  malaria. 

Prognosis. — Different  epidemics  vary  so  much  in  their  extent  and  severity, 
and  individual  cases  in  an  epidemic  present  such  wide  variations  in  the  intensity 
of  their  symptoms,  that  the  outlook  in  each  case  must  be  judged  upon  its  own 
merits.  In  some  epidemics  of  considerable  extent  the  mortality  has  been  nil, 
while  in  others  it  has  reached  as  high  as  50  per  cent.,  or  even  80  per  cent.,  of 
those  attacked.  The  greatest  mortality  occurs  during  the  sweating  stage. 
Epidemics  vary  much  in  their  duration,  the  usual  time  of  prevalence  being 
from  one  to   four  weeks. 

Treatment. — At  one  time  attempts  were  made  to  abort  or  stay  the  severity 
of  the  disease  by  covering  the  patient  Avarmly  and  administering  diaphoretic 
remedies.  This  practice  was  very  justly  abandoned,  and  it  would  seem  that 
the  expectant  plan  of  treatment  is  the  best.  The  diet  should  be  light, 
easily  digestible,  and  nutritious.  The  patient  should  be  lightly  covered,  and 
cool  acidulated  drinks  may  be  permitted.  Quinine  in  moderate  doses  has 
seemed  to  have  some  beneficial  influence.  Stimulants  should  be  given  in 
accordance  with  the  condition  of  the  patient;  they  are  not  required  in  the 
milder  cases.  After  recovery  tonics  are  needed  to  restore  the  patient  to  his 
former  condition. 


MILK-SICKNESS 

By  WILLIAM  PEPPER. 


Definition. — An  acute  disease  occun-ing  in  the  sparsely-settled  and  uncul- 
tivated regions  of  the  United  States,  primarily  affecting  cattle,  but  also  attack- 
ing human  beings  as  the  result  of  eating  the  flesh  or  drinking  the  milk  of  ani- 
mals so  affected ;  characterized  by  great  weakness,  marked  constipation,  vom- 
iting, foetor  of  breath,  and  twitching  of  muscles. 

Synonyms. — Trembles  ;  Slows ;  Puking  fever  ;  Sick  stomach. 

During  the  early  settlement  of  various  portions  of  the  central  region  of  the 
United  States  this  disease  Avas  very  prevalent  and  of  great  virulence.  As  civ- 
ilization advanced  and  the  land  became  more  highly  cultivated,  it  gradually 
disappeared  from  regions  where  it  formerly  abounded,  until  at  the  present 
time  it  is  limited  to  a  few  localities  of  small  area  in  but  a  few  of  the  States 
lying  west  of  the  Alleghany  Mountains. 

Etiology. — Several  theories  have  been  advanced  in  the  attempt  to  arrive 
at  the  cau.se  of  this  affection,  but  as  yet  none  has  been  found  that  furnishes  a 
satisfactory  explanation  of  its  mode  of  production.  It  most  commonly  occurs 
in  summer  and  autumn,  and  is  more  prevalent  in  years  of  drought  and  in 
hot  and  dry  weather.  The  three  theories  that  have  been  most  strenuously 
advocated  as  explaining  its  causation  are — (1)  that  the  poisonous  principle  is 
furnished  by  some  variety  of  rhus ;  (2)  that  it  is  due  to  a  mineral  poison  con- 
tained in  the  drinking-water  of  cattle  in  the  area  affected  ;  and  (3)  that  it  is 
produced  by  a  miasm.  Regarding  the  first  of  these  theories,  which  is  much 
more  rational  than  the  others,  it  may  be  said  that  the  point  has  not  been 
proven,  and  that  the  history  of  its  propagation  and  transmission  from  animals 
to  man  and  from  diseased  animals  to  healthy  animals  through  the  ingestion  of 
the  flesh  or  milk  of  the  former  would  point  toward  some  poison  capable  of 
increase  in  the  animal  body,  rather  than  toward  one  that  attained  its  highest 
development  while  existing  in  itJs  natural  condition  as  a  plant.  The  second 
theory  is  untenable  from  the  well-established  fact  that  laborers  who  have 
drunk  of  the  same  water  as  animals  that  became  diseased  failed  to  be  affected, 
although  the  consuming  of  the  flesh  or  milk  from  such  animals  produced  the 
disease  in  man.  Against  the  third  theory  all  that  need  be  said  is  that  the 
fencing  in  of  limited  areas  of  a  farm  may  cause  the  total  cessation  of  the  appear- 
ance of  the  disease — a  measure  that  would  have  no  effect  were  the  disease 
projxigated  by  a  miasm. 

Symptomatology. — -The  symptoms  in  animals  occur  at  times  with  great 

204 


MORBID    AX  ATOM  V.  205 

abruptness  ;  at  other  times  the  onset  of  the  disease  is  shjw.     The  former  man- 
ner of  attack  is  most  frequently  observed  after  the  animal  has  nnderu;one,  or 
while  it  is  undergoing,  some  unusual  amount  of  physical  exertion.     The  chief 
and  characteristic  symptoms    are — marked    muscular  weakness  with  tremor 
upon  motion,  inability  to  stand,  at  times  vomiting,  and  a  j)eculiar  fcetor  of  the 
breath.    The  tremor  may  amount  to  a  positive  convulsion  ;  tiic  inability  to  stand 
may  develop  so  suddenly  that  the  animal  drops  during  or  alter  exertion,  and 
lies  trembling  in  every  muscle  and  tossing  the  head   from  side  to  side.     In 
man  the  disease  is  ushered  in  by  chilly  feelings  with  hot  flushes,  by  pain  in 
the  head  and  limbs,  with  great  muscular  debility.     With  this  weakness  there 
is  marked  unsteadiness  in  performing  muscular  acts  or  even  tremor  of  the 
muscles  at  rest.     There  are  also  developed  various  disorders  of  the  digestive 
tract.     There  is  marked  foetor  of  the  breath,  the  odor  being  described  as  cha- 
racteristic and  being  likened  to  various  odors  or  combinations  of  odors  of 
familiar  objects,  being  most  frequently  said  to  resemble  that  of  chloroform  and 
the  odor  produced  by  mercurial  salivation!     The  tongue  is  coated  and  marked 
by   the    teeth ;    later,  dry,  fissured,  and    swollen.      Vomiting  is  a   frcfjucnt 
symptom,  the  vomited  matters  consisting  first  of  the  food  last  ingested,  later 
of  a  peculiar  "soapy"  material  of  a  yellowish  or  greenish  hue,  or  it  may  con- 
sist of  mucus  stained  with  blood  or  of  a  material  resembling  coffee-grounds. 
With  these  symptoms  there  is  associated  marked  tenderness  in  the  epigastric 
region,  with  a  sense  of  oppression.     The  bowels  are  obstinately  constipated. 
The  pulse  is  at  first  full,  but  later  becomes  small  and  rapid.     The  temperature 
is,  as  a  rule,  elevated  somewhat,  save  in  the  cases  of  sudden  and  violent  onset, 
when  it  may  be  subnormal.     The  skin  of  the  trunk  may  feel  hot  to  the  touch, 
while  the  extremities  are  cool.     Respiration  is  frequently  much  embarrassed 
in  the  severe  cases. 

Prior  to  death  the  patient  may  pass  into  a  typhoidal  condition,  while 
delirium,  hiccough,  and  coma  frequently  appear.  The  patient  may  be  vio- 
lently attacked  and  die  within  a  few  hours  ;  usually,  however,  the  disease 
continues  for  from  three  to  five  days  before  either  death  comes  or  convalescence 
begins.  The  latter  is  usually  announced  by  a  copious  cvacuntidn  of  the  bow- 
els, and  is  apt  to  be  very  protracted. 

Morbid  Anatomy. — P>ut  few  opportunities  for  necropsies  have  been 
afforded,  but  in  those  made  the  appearances  fi)imd  coincide  closely  with  those 
noted  by  Graff  in  animals  killed  experimentally  by  the  ingestion  of  flesh  from 
diseased  cattle.  These  pathological  findings  .arc,  in  brief,  as  follows:  Cerebral 
sinuses  much  distended  with  blood  ;  marked  congestion  of  cerebral  and  spinal 
meningeal  vessels;  pia  mater  opaciue  and  (•overe<l  willi  purulent  exudate; 
brain  soft;  stomach  and  small  intestines  contracted  and  their  nineous  mem- 
brane injected  ;  liver  and  spleen  soft,  the  latter  l>eing  enlarged  to,  in  many 
cases,  twice  its  normal  size;  liver,  spleen,  lungs,  and  kidiievs  fnll  of  I)lood  ; 
blood  fluid.  The  above  conditions  point  dearly  to  an  infcetious  jjrocess. 
The  occurrence  of  meningitis  is  of  special  importance,  and  sugg(>sts  possible 
analogies  with   irregular  cercbnt-spinid   f<vei-. 


206  MILK-SICKNESS. 

Diagnosis  and  Relation  to  Other  Diseases. — In  those  regions  where 
the  disease  is  known  to  occur  the  diagnosis  is  readily  made  by  noting  the 
presence  of  the  characteristic  tremor,  the  peculiar  odor  of  the  breath,  and  the 
obstinately  constipated  condition  of  the  bowels.  The  affections  with  which  the 
disease  is  most  apt  to  be  confounded  are  those  resulting  from  poisoning  by' 
corrosive  mineral  substances.  From  these  it  may  be  distinguished  by  the 
tremor  and  by  the  absence  of  diarrhoea.  From  poisoning  by  animal  toxines 
the  diagnosis  would  be  more  difficult ;  and,  in  fact,  this  disease  itself  may  in 
the  future  be  found  to  be  due  to  the  ingestion  of  ptomaines.  The  absence  of 
diarrhoea  would  separate  this  from  most  of  the  known  forms  of  animal 
poisoning. 

Treatment. — Formerly,  when  the  disease  was  much  more  prevalent  than 
at  present,  much  dependence  was  placed  upon  the  employment  of  venesection 
and  calomel  in  the  treatment  of  this  as  of  every  other  affection.  It  was  soon 
found,  however,  that  not  only  did  these  measures  fail  to  produce  a  cure,  but 
that  they  frequently  tended  to  increase  the  severity  of  the  symptoms.  The 
most  rational  treatment  is  symptomatic  and  expectant.  The  external  applica- 
tion of  counter-irritants  to  the  epigastrium,  with  the  internal  administration 
of  antiemetics,  such  as  carbolic  or  dilute  hydrocyanic  acid,  and  the  use  of 
appropriate  quantities  of  alcohol  or  other  cardiac  stimulant,  would  seem  to 
fulfil  the  indications.  Large  enemata  of  water  or  oil  have  been  used  with 
asserted  good  results.  Prophylactic  measures  are  to  be  rigorously  employed. 
Tracts  of  land  where  affected  cattle  have  been  grazing  should  be  fenced  off  in 
order  to  prevent  the  access  of  other  cattle.  All  animals  found  to  be  affected 
by  the  disease  should  be  killed  and  the  carcasses  buried  at  once.  Where  the 
disease  is  suspected  to  be  present,  though  latent,  forced  exertion  may  cause  the 
characteristic  symptoms  of  the  disease  to  exhibit  themselves. 


MOUNTAIN  FEVER. 

By  WILLIAM  PEPPER. 


Although  there  are  in  medical  literature  aecounts  of  various  anomalous 
fevers  to  which  special  names  have  been  a})plied,  it  seems  desirable  to  allude 
here  only  to  "  mountain  fever,"  by  which  name  has  been  desijjjnated  a  mild 
type  of  infectious  fever  observed  in  the  Rocky  Mountain  region  of  the  United 
States.  It  must  not  be  confounded  with  the  acute  indisposition  which  not 
rarely  develops  soon  after  ascent  to  a  high  altitude.  The  symptoms  of  this 
are  properly  referred  to  the  action  of  the  rarefied  air  upon  the  circulation  and 
respiration.  They  are  exhaustion  on  exertion,  headache,  giddiness,  sometimes 
nausea  and  vomiting,  marked  dyspnoea,  and  undue  rapidity  of  the  pulse.  Ei)i- 
staxis  often  occurs,  and  the  temperature  may  be  ft)und  slightly  elevated.  The 
symptoms  gradually  subside  as  the  subject  becomes  habituated  to  the  altitude. 
Such  results  are  observed  in  all  countries,  and  are  develoi)ed  at  different  alti- 
tudes in  accordance  with  the  cardiac  and  nervous  force  of  the  individual. 

But  the  group  of  cases  to  which  the  term  "mountain  fever"  has  usually 
been  applied  present  the  symptoms  of  an  irregular  continued  fever.  The  dura- 
tion is  from  two  to  four  weeks  or  longer ;  the  fever  is  moderate,  the  tempera- 
ture ranging  between  101.5°  and  103°,  and  rarely  passing  104°  F.  The  marked 
irregularities  in  the  fever  and  the  apparent  efficiency  of  quinine  in  certain  cases 
have  led  spme  observers  to  believe  in  the  malarious  nature  of  the  affection. 
Smart  in  particular  advocated  this  view  in  1878,  and  traced  the  origin  to  a 
water-supply  tainted  with  deleterious  vegetable  matters  which  had  been  carried 
by  the  winds  to  the  snow  on  the  upper  Tevels.  Cerebral  symptoms  are  not 
marked.  The  bowels  are  usually  constipated,  rarely  relaxed.  Rigor,  lassi- 
tude, occasional  epistaxis,  have  been  noted  in  the  early  days.  No  characteristic 
eru|)tion  apj>ears.  The  spleen  is  usually  enlarged.  Pulmonary  complications 
occasionally  occur.  Curtin  refers  to  four  cases  called  mountain  lever  in  which 
croupous  pneumonia  existed  as  a  comjilication,  if  it  did  not  constitute  the  entire 
disease.  Few  cases  have  died,  and  but  two  j)ost-mortem  examinations  are 
recorded.  In  both  the  typical  lesions  of  typhoid  fever  were  present,  and  |)er- 
foration  of  the  ileum  hadocciu'red  in  one  case.  There  woukl  seem  td  \)v  little 
doubt  that  such  is  the  true  nature  of  nearly  all  cases  of  this  form  of  inoinitain 
fever.  It  is  fair  to  assume  that  the  effect  of  the  high  altitude  would  modily 
somewhat  the  sym))toms  of  the  disease.  I(  may  be  admitted  that  sometimes 
a  malarial  element  is  associated,  and  that  in  rare  instances  the  alTeetion  may  be 
simply  a  malarial  remittent  fever.  It  is  clear,  therefore,  that  uo  atle(|uate  rea- 
son exists  to  longer  continue  a  separate  description  of  a  disease  wlii<li  eamiot 

be  shown  to  jwsscss  distinctive  features. 

207 


SCARLATINA. 

By  JAMES  T.  WHITTAKER. 


Synonyms. — Rubores;  Purpura  (Forestus);  Rossalia  (Ingrassias)  ;  Scarlet 
fever ;  Ger.  Scharlach. 

Definition. — Scarlatina,  from  the  (old)  Italian  scarlattina,  scarlatto  (red), 
is  a  treacherous,  acute,  contagious  infection,  characterized  by  a  more  or  less 
typical  fever,  inflammation  of  the  throat,  a  diffuse  scarlet  exanthem,  followed 
by  membranous  exfoliation  of  the  skin,  occasionally  by  otitis,  exceptionally 
by  arthritis,  and  not  infrequently   by   nephritis. 

The  first  use  of  the  term  febris  scarlatina  is  found  in  a  comment  by  Lan- 
celotti  of  Italy  (1527),  but  it  was  not  distinctly  applied  to  the  affection  as  we 
know  it  until  by  Sydenham  (1661),  who  first  separated  it  from  measles,  with 
which  it  had  hitherto  been  confounded.  Sydenham  saw  only  mild  cases.  He 
considered  the  disease  "only  an  ailment,  we  can  hardly  call  it  more,"  but  was 
able  to  recognize  it  without  the  help  of  throat  symptoms,  which  he  does  not 
mention  in  his  brief  description. 

It  was,  however,  a  full  century  after  Sydenham  before  the  ability  to  sep- 
arate scarlatina  became  common  property,  and  no  sooner  was  it  firmly  set 
upon  its  tripod  of  symptoms,  to  wit,  fever,  exanthem,  angina — that  is,  no 
sooner  were  the  throat  symptoms  established  as  an  integral  factor  of  the  dis- 
ease— than  it  became  confounded  with  diphtheria  as  much  as  it  had  ever  been 
with  measles.     Irregular  cases  of  either  are  not  yet  easily  disentangled. 

Whence  it  was  originally  imported  or  when  it  first  appeared  in  Euro]^e  is 
unknown,  but  it  was  first  recognize'd  in  England  in  1661  ;  Scotland  in  1716  ; 
Germany  and  Italy  in  1717  ;  Denmark  in  1740  ;  North  America,  at  Kingston 
and  Boston,  in  1735,  New  York  and  Philadelphia  in  1746,  Ohio  and  Ken- 
tucky in  1791,  Toronto  in  1843,  New  Orleans  in  1847,  California  in  1851. 

The  disease  is  rare  in  Asia  and  Africa,  and  is  said  to  be  (Wernich,  1871) 
entirely  unknown  in  Japan.  Scarlatina  is  therefore  much  less  widely  dissemi- 
nated than  measles  and  small-pox,  both  of  which  have  repeatedly  ravaged  Asia 
and  Africa. 

A  pronounced  peculiarity  of  scarlatina  in  distinction  from  measles  and 
small-pox  is  the  variation  in  the  intensity  of  epidemics,  which  are  sometimes 
so  mild,  as  in  the  time  of  Sydenham,  that  the  aflFection  "  vix  nomen  morbi  mere- 
batur  "  (scarcely  deserved  the  name  of  a  disease),  and  again  virulent  and  malig- 
nant, more  especially  in  villages  and  small  towns,  with  a  mortality  as  great  as 
that  of  cholera  and  the  plague.  ^^  Malum  hoc  grave,^^  said  Sennert  almost 
simultaneously  with  Sydenham,  " perwidosum  et  scepe  lethale  est."  Breton- 
neau    never   saw  a  single  fatal  case  of  scarlet  fever  for   twenty-four   years 

208 


SCAI^LATIXA.  209 

(1799-1823)  in  all  his  practice,  but  in  1825  he  enoountered  an  epidemic 
so  virulent  as  to  cause  him  to  entirely  change  his  opinion  re<rartling  the 
benignity  of  the  disease.  From  1801-04  the  epidemics  of  Dubliirwere 
marked  by  great  malignancy,  but  the  character  of  the  disease  changal  in 
1804,  and  for  the  next  twenty-seven  years  it  was  mild  and  benign.  "  What 
was  more  natural,"  Graves  exclaims,  "  than  that  the  difference  should  have  been 
ascribed  to  our  improvements  in  treatment?"  But  in  1834-35  there  was  bitter 
disillusion.  The  disease  reappeared  in  virulence  and  malignancy,  and  in  total 
defiance  of  hitherto  successfid  methods  of  treatment.  Lewis  Smith  relates  that 
a  distinguished  physician  of  New  York  treated  more  than  fifty  cases  of  scarlet 
fever  in  one  of  the  hospitals  without  a  single  death  :  a  few  months  later  the 
type  changed,  and  his  own  son  died  of  the  disease. 

That  this  virulence  is  not  due  to  the  accumulation  of  susceptible  material  in 
long  intervals  of  absence  is  proven  by  the  experience  of  Kostlin  of  Stuttgart, 
who  observed  an  epidemic  in  1846  so  mild  as  to  be  without  a  single  death  fol- 
lowing an  interval  free  of  scarlatina  for  a  period  of  sixteen  years.  Soil,  season, 
or  climate  offers  no  explanation  of  this  peculiarity  ;  we  remain  as  yet,  in  the 
language  of  Drake,  "  entirely  ignorant  of  the  causes  or  conditions  which 
determine  these  remarkable  diversities  of  phenomena  and  danger." 

Thus  it  may  be  said  that  since  small-pox  has  been  shorn  of  its  terrors 
scarlatina  takes  rank  as  the  most  dreaded  of  all  the  infections  which  now 
prevail.  It  is  estimated  to  cause  one-twenty-fifth  to  one-twentieth  of  the 
whole  mortality  in  England  and  America.  In  the  two  years  1863  and  1864 
scarlet  fever  alone  took  in  England  more  than  60,000  lives.  In  1869  the 
victims  in  London  alone  numbered  5803.  Estimating  prevalence  from  mor- 
tality, making  no  allowance  for  unrecognized  mild  cases,  and  granting  each 
case  but  two  weeks  of  contagiousness,  it  is  claimed  that  London  maintains  a 
permanent  stock  of  2000  centres  of  contagion.  Continuous  or  constant  infec- 
tion is  sustained  in  nearly  all  cities  of  fifty  to  one  htmdred  thousand  inhabitants. 

Etiology. — Susceptibility  to  scarlatina  is  much  less  than  to  measles 
and  small-pox,  one  member  of  a  large  family  being  often  alone  attacked. 
Hence  the  majority  of  individuals  escape  it  throughout  life.  Individual 
families  seem  predisposed  to  or  exempt  from  the  disease.  Ziemssen  says 
he  saw  cases  which  annihilated  the  posterity,  and  jiraetitioners  everywhere 
have  become  demoralized  by  the  loss  of  one  ineml)er  after  another  of 
a  family,  to  literally  extinguish  it.  On  the  other  hand,  the  family  of 
the  physician  himself,  exposed  to  frequent  infection,  may  entirely  escape 
attack.  It  is  difficult  to  find  any  explanation  for  this  individual  or 
family  immunity  until  at  least  the  etiology  of  the  disease  shall  have  been 
definitely  established.  Geil  makes  an  attempt  at  oiw  with  the  assump- 
tion that  the  cause  of  the  disease  is  received  into  the  throat,  ami  may 
take  hold  only  upon  a  broken  surface.  The  absent  <ir  hk-ic  or  l.'ss  lavoral)le 
nidus  in  the  throat  denies  or  admits  the  disease,  fixes  the  period  oC  incubation, 
the  amount  of  the  infection,  the  intensity  of  attack,  etc.  The  ex|)laiialiou  is 
seductive  in   its  simplicity,  and   is  based   upon   the  infection  of  wounds  and 

Vol.  I.— 14 


210  SCARLATINA. 

puerperiiim,  but  is  open  to  the  valid  objection  that  the  necessity  of  a  broken 
surface,  as  in  the  case  of  syphilis  or  hydrophobia,  is  not  proven  of  scarlatina. 
The  new  doctrines  of  defensive  serums  will  probably  soon  clear  up  this  obscure 
field.  This  extensive  immunity  and  individual  liability  accounts,  however,  for 
the  fact  that  while  epidemics  of  scarlatina  are  much  less  frequent  than  measles, 
decades  often  intervening,  individual  cases  are  much  more  common. 

It  is  said  that  children  have  been  born  at  various  stages  of  the  disease,  but 
it  must  be  remembered  that  hypersemia  and  desquamation  occur  frequently  in 
the  new-born  in  health.  The  curious  observation  has  been  made  of  infants 
that,  though  lying  constantly  by  the  side  of  mothers  affected  with  the  disease, 
they  escape  almost  without  exception — proof  that  the  exemption  of  sucklings 
is  innate,  and  is  not  due  to  the  greater  protection  of  them  from  exposure.  The 
age  of  predilection  ranges  from  two  to  seven.  Sixty  per  cent,  of  cases  occur 
before  the  age  of  five,  90  per  cent,  under  ten.  Attacks  later  in  life  are  rare, 
and  are  usually  mild.  Here  too,  however,  are  observed  the  same  differences 
in  epidemics.  Thus,  in  Ziemssen's  report  the  mortality  among  adults  in 
1865-75  was  11.5  per  cent.,  and  in  1876-87  but  1.3  per  cent. 

One  attack  confers  immunity,  as  a  rule,  for  life.  With  an  observation  of 
2000  cases  Willan  never  saw  it  repeat  itself.  A  second  attack  is  possible,  but 
rare,  and  occurs  more  especially  in  cases  of  exposure  in  more  advanced  life  in 
taking  care  of  a  younger  member  of  a  family  affected  with  the  disease.  These 
secojid  attacks  are,  as  a  rule,  so  abortive  or  rudimentary  as  to  be  easily  over- 
looked, and  are  recognized  at  times,  as  are  first  attacks  in  the  mildest  cases, 
only  by  sequelre.  Hence  the  suspicion  may  be  entertained  that  some  of  the 
insusceptibility  of  certain  individuals  may  be  immunity  conferred  by  an  attack 
so  mild  as  to  have  been  considered  an  ephemeral  affection.  Subsequent  attacks 
may  be  accepted  only  when  properly  attested,  distinctly  marked,  or  attended  or 
followed  by  recognized  complication  or  sequel.  Thus,  Thompson  saw  a  second 
attack  followed  by  dropsy  three  years  after  a  first  which  affected  also  other 
members  of  the  family.  Richardson  declared  that  he  had  it  three  times  him- 
self, and  Stiebel  records  a  remarkable  case  in  a  woman  aged  fifty  who  suffered 
four  attacks  in  four  successive  years — a  frequency  which  must  call  out  some 
doubt — with  desquamation  each  time  "  in  parchment-like  pieces  half  a  foot  in 


length." 


Most  so-called  repeated  attacks  (aside  from  relapses  to  be  noticed  later)  are 
mistakes — erythema,  rubella,  septic  rashes,  etc. ;  and  the  rule  that  scarlatina 
occurs  but  once  remains  to  constitute  important  evidence  in  diagnosis. 

Pregnancy  certainly  protects  against  it,  but  the  puerperium  and  open 
wounds  of  any  kind  invite  it. 

Regarding  puerperal  scarlatina,  caution  must  be  entered  against  confound- 
ing it  with  septicaemia,  which  often  shows  fever  and  eruptions  (erythema) 
simulating  scarlatina.  There  is  no  doubt,  however,  that  the  puerperal  state 
confers  additional  susceptibility  to  scarlatina.  Primiparse  are  most  liable  to 
attack,  but  in  all  cases  the  disease  sets  in  or  shows  itself  close  about  the  period 
of  delivery,  Mithin  the  first  week.    Attack  later  is  exceedingly  rare.    In  proof 


SCAIiLATIXA.  211 

of  the  increased  susceptibilitj  of  the  puerperal  state,  Boiisall  declared  of  his 
cases  that  10  had  had  scarlatina  before,  and  1  had  had  it  twice. 

In  puerperal  cases  the  eruption  occurs  more  (piickly,  almost  suddenly. 
The  throat  symptoms  are  much  milder  or  are  absent  altooether,  while  local 
lesions  about  the  vulva  and  uterus  predominate. 

With  reference  to  surgical  scarlatina,  so  called,  the  same  caution  must  be 
entertained  to  prevent  confusion  with  erysipelatous,  crytiiematous,  or  other 
eruptions  of  septicemia.  ]Many  of  the  cases  rej^orted  will  not  stand  under 
close  analysis.  There  is,  however,  good  authority  (Paget,  Playfair)  for  the 
coincidence,  and  there  is  no  reason  why  the  jwssibility  of  it  should  be  denied. 
In  the  light  of  existing  knowledge  no  physician  or  surgeon  in  attendance  upon 
a  case  of  any  infection  may  attend  a  case  of  labor  without  i)revious  thorough 
disinfection. 

The  disease  is  conveyed  bv  contact  direct  or  indirect,  as  bv  clothinir 
eminently,  washing,  bedding,  furniture,  letters,  books  (as  from  a  library  or 
school),  toys,  etc.  A  not  infrequent  source  of  infection  is  milk,  sometimes 
from  an  infected  dairy.  Perhaps  the  most  instructive  example  of  this  source 
of  contagion  was  furnished  by  iMiller,  who  reported  2-4  cases  of  infection  in 
this  way.  The  daughter  of  a  dairyman  near  Brewster,  New  York,  made  a 
visit  to  the  city.  On  the  day  after  her  arrival  she  fell  ill  with  scarlet  fever. 
Two  weeks  after  her  recovery  she  returned  home.  Two  weeks  later  her 
youngest  sister,  who  slept  with  her,  showed  signs  of  the  flisease.  The  health 
officer  ordered  that  the  dairy  business  should  be  conducted  away  from  the 
house.  Nevertheless,  three  weeks  later  a  number  of  cases  broke  out  in  the 
village.  By  the  fourth  week  12  cases  were  reported.  Investigations  showed 
that  every  one  who  had  the  fever  had  drunk  the  milk,  but  not  one  who  did 
not  drink  it  was  affected.  The  injunction  of  the  health  officer  had  been  obeyed, 
but  the  milkman  had  washed  and  wiped  his  cans  with  white  flannel  clothes 
left  in  the  barn  by  a  peddler  of  rags,  which  were  probably  the  cause  of  the 
first  infection.     In  all,  24  cases  developed  directly  from  driidung  the  milk. 

The  disease  may  be  conveyed  also  by  third  ])ersons,  who  may  carry  the 
])oison  in  their  hands,  hair,  or  clothing,  but  may  themselves  remain  exenijjt. 
Convalescents  from  the  disease  carry  it  to  school,  church,  theatre,  train,  clc, 
and  disseminate  it  throughout  a  community. 

The  cause  of  the  disease  is  said  to  be  disseminated  from  tlic  skin  as  well  as 
the  various  secretions,  and  to  be  given  off  during  incubatittn  and  destpiama- 
tion,  as  well  as  during  the  stage  of  eruj)ti()n.  Upon  this  subji-ct  there  is  need 
of  more  exact  information.  Scarlatina  is  undoubtedly  c(>ntagi<»ns  in  llic  strict 
sense  of  the  term.  Every  case  owes  its  origin  (o  a  previous  case.  Tlic  dis- 
ease never  originates  de  novo ;  but  it  is  not  yet  dctermincil  in  wlmt  \\:iy  the 
poison  is  disseminated.  It  is  believed  (hat  it  circidates  in  the  blood  to  con- 
taminate and  infect  the  various  exhalations  and  excretions.  It  is  pi-ob:ible  that 
the  disease  is  conveyed  by  exhalations,  or  nither  excretions,  iVoin  the  throat, 
which  are  received  by  inhalation  (eontagium  h.-ilitno^um)  into  the  throat,  where 
it  shows  its  first  signs.     Children  have  been  born,  as  staid,  in  every  stage  of 


21 2  SCARLA  TINA . 

the  disease  from  incubation  to  desqnamation.  Infection  in  these  last  cases 
conld  have  occnrred  only  through  the  blood.  More  importance  is  to  be 
attached  to  this  fact  than  to  any  inoculations  of  lower  animals,  as  in  the  well- 
known  experiments  of  Coze  and  Feltz,  because  the  symptoms  which  resulted 
were  not  typical  or  under  comparison  with  so-called  *' control  observations." 
Thev  miolit  have  occurred  with  other  inoculations.  The  attempts  of  Williams, 
Rostan,  and  Miquel  at  inoculation  with  a  view  of  inducing  a  milder  Init  pro- 
tective attack  for  the  most  part  failed,  and  contradictory  testimony  is  fur- 
nished (Radel,  Stoll)  as  to  the  propagation  of  the  disease  by  means  of  the  skin. 
It  is  assumed,  rather  than  proven,  that  the  poison  of  scarlatina  exists  in  the 
skin.  The  claim  is  more  definitely  made  of  small-pox.  It  may  be  con- 
sidered, in  fact,  established  of  this  disease  by  inoculation.  There  are  eminent 
clinicians  ( Volz)  who  deny  all  infection  to  the  skin,  or  (notably  Leyden)  who 
maintain  that  the  eruption  of  scarlatina  is  to  be  looked  upon  as  only  a  reflex 
phenomenon,  like  that  of  erythema  from  gastric  catarrh  or  like  a  toxic  (drug) 
eruption,  in  which  case  it  would  be  useless  to  look  for  the  poison  in  the  skin. 
At  the  present  time,  for  the  sake  of  safety,  it  is  wise  to  believe  in  dissemina- 
tion from  the  skin,  and  to  act  accordingly.  It  is  singularly  tenacious,  adhering 
to  clothing;  after  months  of  disuse  and  to  rooms  after  months  of  vacation  and 
seemingly  thorough  disinfection  and  ventilation.  Thus,  Von  Hildebrandt's 
coat  retained  its  contagiousness  for  a  year  and  a  half.  Adams  reports  that 
he  found  the  disease  to  have  been  communicated  by  a  convalescent  who  showed 
no  signs  of  ill-health  as  late  as  the  forty-third  day.  In  the  experience  of  the 
writer  the  opening  of  a  closet  in  a  house  vacated  for  three  months  after  the 
death  of  a  child,  and  the  handling  of  garments  suspended  in  it,  coili  muni  cat  ed 
the  disease  to  another  child  of  the  same  family. 

Surgeon  Brooke,  U.  S.  A.,  detailed  an  instance  of  apparently  spontaneous 
scarlatina  in  a  child  that  had  been  subject  to  no  discernible  exposure.  It  was 
subsequently  ascertained  that  one  of  the  domestics  had  nursed  a  case  of  scarlet 
fever  in  a  distant  city  a  year  before.  Some  of  the  clothing  which  she  had 
worn  at  the  time  was  packed  away  in  a  trunk,  and  this  trunk  had  been  opened, 
the  contents  removed  and  handled  by  the  child  a  short  time  before  the  attack. 
The  poison  of  scarlatina  literally  lurks  in  long-discarded  clothes. 

An  illustrative  case  is  also  reported  by  Richardson  of  London.  A  family 
consisting  of  a  man,  his  wife,  and  four  children  lived  in  a  small  thatched  cot- 
tage. One  of  the  children  was  attacked  Avith  scarlet  fever  and  died.  The 
remaining  children  were  removed  four  or  five  miles.  After  several  weeks  one 
of  them  was  allowed  to  return.  This  one  took  sick  within  twenty-four  hours 
and  quickly  died.  The  cottage  was  now  thoroughly  cleansed  and  white- 
washed, the  floors  scoured,  and  the  wearing  apjiarel  destroyed.  Four  months 
later  another  of  the  children  returned,  to  be  stricken  down  with  the  disease 
in  malignant  type  on  the  following  day.  The  author  believed  that  the 
poison  had  become  fixed  in  the  thatched  roof,  whence  it  could  not  be  dis- 
lodged. 

This  tenacity  of  life  is  counteracted  in  great  degree  by  limitation- of  range. 


SCAIILATIXA.  213 

The  poison  of  scarlatina  is  not  witlely  disseminated.  On  the  contrary,  its 
area  of  distribution  is  confined  to  very  narrow  limits.  The  field  of  infection 
is  pretty  closely  circumscribed  about  the  body.  The  poison  is  entangled  as  a 
particulate  body  in  the  texture,  or  is  fixed  upon  the  surface  of  fomites.  It  is 
therefore  nnich  easier  to  sequestrate  cases  of  scarlatina  than  measles,  and  thus 
to  protect  other  members  of  a  family  or  house.  Confinement  to  a  ditl'erent 
storv  of  a  house  or  to  a  room  absolutely  isolated  in  its  ins  and  outs — that  is, 
in  its  exits  as  well  as  entrances  of  attendants  and  things — will  generally  suf- 
fice. Stay  in  an  adjoining  room  with  separate  entrances,  though  with  an 
unopened  door  between,  has  proven  protective. 

The  tenacity  of  the  poison — that  is,  the  maintenance  of  the  disease — is 
helped  also  by  its  intensity.  But  very  short  contact  with  a  case  suffices  for 
infection.  Thomas  quotes  from  Palante  the  casi'  of  a  mother  in  contact  with 
a  patient  "  but  a  moment,"  who  returned  immediately  to  her  home  at  a  dis- 
tance of  six  miles,  but  whose  contact  had  been  long  enough  to  collect  and 
carry  the  disease  to  her  children,  in  whom  it  showed  itself  in  the  coui*se  of  a 
few  days ;  and  from  Hennig  the  case  of  a  child  attacked  four  days  after  asso- 
ciation "  but  for  a  short  time"  with  another  child  which  had  had  the  disease 
six  weeks  before.  The  mere  handling  of  woollen  goods,  clothes,  shawls, 
blankets,  curtains,  furniture  covers,  etc.  has  repeatedly  conveyed  the  disease. 

Cold  does  not  affect  it.  It  is  destroyed,  however,  by  heat,  by  boiling  water, 
especiallv  by  steam,  and  quickly  by  steam  in  motion,  so-called  "live* steam." 
Henry,  after  subjecting  the  flannel  garments  of  scarlatinous  patients  to  a  dry 
heat  of  212°  F.,  felt  safe  in  having  had  them  worn  by  unaflected  children 
from  six  t(j  thirteen  years  of  age,  and  no  infection  followed. 

Therefore  the  cause  of  scarlatina  must  be  a  micro-organism,  though  it  has 
not  yet  been  definitely  isolated  and  determined.  It  has  been  described  as  a 
Plasmodium,  and  even  as  a  pilz  (mould-fnngus).  Klebs  (1880)  pictured  and 
described  a  structure  found  in  the  blood  as  the  3Ionas  scarlatuiosum.  Eklund 
(Stockholm,  1881),  found  constantly  in  the  urine  as  well  as  in  the  soil  an(l 
ground-water  an  immense  number  of  discoid  corpuscles  without  further  i>roof 
of  pathogenesis  than  presence.  Power,  Cameron,  and  Klein  ^188^-86) 
described  coincidently  with  an  outbreak  of  scarlatina  a  disease  of  cows  in  the 
Hendon  (England)  dairy,  an  acute  general  infiannnation  attended  with  the 
formation  of  pustules  and  ulcers  on  the  bag,  communicable  to  other  animals, 
and  from  the  pustules  as  well  as  from  internal  organs  could  be  isolated  and 
developed  micrococci  (streptococci)  whicii  when  intnxluced  int..  Ii<  l.l-ii.i<v  pro- 
duced the  same  phenomena  as  injections  from  cuhnrcs  from  ih.-  bh.od  i.l 
scarlet  fever  in  man.  Baumgarten  believes  thes.'  sin.cturcs  to  be  varieties  „1 
the  streptococcus  pvogenes.  Marr  (1891)  conten.ls  that  they  .-orrcspon.l  to 
Fliigge's  streptococci,  and  that  the  symptoms  shown  bv  animals  in.hiding 
the  kidnev  affections,  followed   inoculation   by  (.ther  poisons. 

Jamison  and  Eddington  (1887)  were  abh>  t..  isolate  from  the  blood  and 
from  desquamations  of  the  skin  no  h-ss  than  eiudit  dilVerenf  baetena,  one  ol 
whieh,   designated   the   baciUns   scarlatiuic,   introdi.ee.l    into   g.i a-pigs   and 


214  SCARLATINA. 

rabbits,  produced  temporary  fever  and  erythema.  An  inoculated  calf  died 
with  fever  on  the  following  day,  showing  the  same  bacilli  in  the  blood.  The 
bacteria  of  mouse- septicaemia,  rabbit-erysipelas,  and  the  swine-plague  will, 
however,  all  produce  erythema,  and  often  even  desquamation. 

These  various  micro-organisms  are  now  believed  to  be  varieties  of  the  ordi- 
nary pyogenic  bacteria.  It  cannot  as  yet  be  maintained  of  any  of  them  that 
thev  are  found  uniformly  or  only  in  scarlatina,  nor  that  the  disease  produced 
by  them  is  really  scarlatina.  It  is  not  yet  established  that  any  of  the  lower 
animals  are  susceptible  to  the  disease.  It  would  be  more  natural  to  look  for 
the  poison  in  the  tiiroat  and  in  the  blood  in  the  earliest  stage  of  the  disease 
than  in  the  secretions  from  the  kidneys  or  in  the  substance  or  exfoliations 
of  the  skin.  The  kidney  affection  is  doubtless  the  result  of  a  chemical  poison 
in  its  escape  from  the  body,  and  the  exanthem  must  also  be  regarded  as  toxic, 
like  that  produced  by  certain  drugs. 

Luff  has  succeeded  in  eliminatiug  a  hitherto  uuknown  alkaloid  from  the 
urine  of  scarlatina,  and  Leyden  declares  it  to  be  useless  to  look  for  the  poison 
of  scarlatina  in  the  skin. 

Regarding  the  relationship  of  diphtheria,  it  is  admitted  that  one  affection 
may  follow  the  other,  or  that  they  may  even  coincide,  but  in  all  cases  only  as 
exceptions.  The  rule  is  that  the  diseases  prevail  in  communities  and  exist  in 
individuals  independently  of  each  other.  Experimental  evidence  at  the  hands 
of  the  most  competent  and  conservative  observers  multiplies  to  support  this 
view,  which  was  first  clinically  established  by  Henoch  and  Huebner.  It  is  cer- 
tain that  most  of  the  cases  of  so-called  scarlatinal  diphtheritis  distinguish  them- 
selves by  the  absence  of  the  Klebs-Loffler  bacillus,  and  by  the  presence  only 
of  the  streptococcus,  which  stands  in  some,  though  not  specific,  genetic  rela- 
tion to  the  development  of  the  membrane.  When  inoculation  is  made  early — 
i.  e.  so  soon  as  the  membrane  is  visible — on  the  very  first  day  of  its  appearance, 
and  when  the  matter  is  taken  only  from  typical  cases  of  scarlatina,  as  in  the 
.studies  of  Tangl,  the  culture  shows  in  no  cases  the  bacillus  of  diphtheria. 

Course  of  the  Disease. — TJie  period  of  incubation  is  short,  ranging  from 
four  to  seven  days.  Ziemssen  declares  that  the  few  unimpeachable  observa- 
tions that  we  possess  put  it  at  seven  days,  English  writers  make  it  generally 
less,  and  declare  that  from  the  second  day  after  exposure  liability  of  attack 
grows  progressively  less.  In  all  the  twenty-four  cases  mentioned  in  this 
article  as  having  been  caused  by  milk  the  symptoms  showed  themselves 
within  twenty-four  hours  after  the  drinking  of  the  milk.  On  the  other 
hand,  Pons  extends  the  incubation  to  four,  Moore  to  seven,  and  Veit 
to  fourteen  days.  The  most  critical  observers  (Gerhardt,  Thomas)  admit 
these  periods  as  exceptions,  but  place  the  general  average  at  four  to  seven 
days. 

The  invasion  is  usually  sudden  and  violent,  grave,  dangerous,  sometimes 
fatal  illness  developing  within  a  few  hours.  An  initial  chill  or  series  of 
shiverings  is  attended  by  a  quick  and  high  rise  of  tem]ierature.  It  is  more 
frequently  the  case  that  the  disease  is  ushered  in  without  anv  chill  at  all. 


COVRSK    OF    rilE    DISEASE. 


215 


A  child  presents  evidence  of  attack  in  a  shock  nuinilcstcd  l.v  extreme  pallor 
and  prostration.  A  highly  snsceptible,  sensitive  ehil.l  mav  be  seized  with  a 
convulsion.  Usually  the  scene  opens  with  vomiting.  Karly  vomiting  belongs 
to  all  the  grave,  acute  infections,  but  it  occurs  with  especial  frcquencv  in  scar- 
latina, because  of  the  gravity  of  the  disease.  Alter  th.-  vomiting  it'is  noticed 
that  the  patient  has  fever.  Inspection  thus  early  iwi  als  angina  or  the  child 
complains  at  once  of  sore  throat.  Vomiting,  sore  throat,  and  1'ever  at  the  start 
should  excite  the  suspicion  of  scarlatina,  or,  in  the  presence  of  an  epidenn'(! 
or  proximity  of  another  ca.se,  establish  the  existence  of  the  disease.  The 
temperature  distinguishes  itself  by   the  ra|>i(lity   ,.f  its  ascent  (See  Fig.  1,3). 


loa* 


102* 


101 


100* 


99 


Fio.   l.S. 
3        4  5 


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■[■■■■■■■■■■■ichBh 


mi 

HI 


Temperature-charl  of  a  Mild  Case  ol'  Sturluliiiu. 

The  ascent  of  the  temperature  in  scarlet  fever  is  more  rapid  than  in  alnidst 
any  other  disease,  reaching  often  within  twenty-four  to  forty-eight  hours 
104°  to  107°  F.  Calor  mordax  was  the  term  applied  by  the  older  pic- 
thermometric  writers  to  express  the  biting  heat  of  the  skin.  If  there  is 
no  question  of  complications,  the  fever  reaches  its  height  w  ith  the  appearance 
of  the  eruption,  or  at  least  with  its  fidl  efflorescence,  to  gradually  subside  in 
the  course  of  one  or  two  wrecks  in  a  mild  or  sharp  average  case  respectivclv. 
In  cases  in  which  the  eruption  "siid^s  in  "  or  disa|)j)ears  in  the  face  of,  or  is  a 
residt  of,  a  grave  complication,  the  coldness  of  the  surface  is  onlv  apparent. 
The  thermometer  in  the  rectum  or  vagina  i-egisters  high  grailes  (1().")°  to  1()S° 
F.),  to  fall,  often  rapidly,  under  a  hot  bath,  which  may  bring  the  lilood,  aiitl 
with  it  the  eruption,  to  the  surface.  The  persistence  of  (he  complicalioii, 
meningitis,  pneumonia,  etc.,  re])ro(hices  the  surface  coldness  after  (lie  ba(h. 

In  correspondence  with  the  height  of  this  fever,  especially  in  yoimg  chil- 
dren, nervous  signs,  as  stated,  show  themselves — viz.  deliriinii  .iml  coii\iil 
sions.  The  delirium  may  deepen  rapidly  iiid*  coma.  'fherc  i<  in  evciy 
marked  case  profound  jirostration.  It  is  seen  on  the  most  superficial  inspec- 
tion that  the  child  is  seriously  ill.  This  stage  of  invasion  lasts  from  one  lo 
two  days.  Comment  has  been  made  upon  the  irrcgnl:iii(y  or  varic(y  in  sever- 
ity of  epidemics  of  scarlatina.     The  same  varic(y  is  noticed  in   individual  ca<es 


216  SCABLATIXA. 

of  the  same  epidemic.  In  the  same  family  side  by  side  with  a  malignant  case 
occurs  an  attack  so  mild  that  it  may  be  scarcely  recognized.  Lightly-affected 
brothers  and  sisters  may  be  playing  about  the  house  where  one  member  lies 
fatallv  ill  or  has  just  fallen  a  victim  to  the  disease.  So  there  may  be  every 
o-rade  of  intensity  in  the  onset,  but  as  a  rule  the  disease  is  announced  by  a 
sudden  attack  of  fever  attended  by  vomiting,  which  assumes  more  and  more 
importance  when  it  may  not  be  accounted  for  by  a  sufficient  provocation,  as 
by  indigestion,  or  by  other  infection — croupous  pneumonia,  cerebro-spinal 
meningitis,  small-pox,  etc. 

In  the  absence  of  these  symptoms  the  diagnosis  must  be  held  in  abey- 
ance until  the  appearance  of  the  eruption.  The  eruption  shows  itself  in  from 
twelve  to  twenty-four  hours  after  the  initial  symptom — chill,  vomiting,  or  shock 
— on  the  face,  over  the  forehead,  cheeks,  the  chin,  and  often  at  the  same  time — 
as  a  rule,  in  fact — the  clavicles.  Here,  at  least,  it  is  first  seen.  When  search 
is  made,  it  may  usually  be  discovered  soonest  on  the  neck,  breast,  and  back. 
It  usually  spares  or  skips  the  region  of  the  mouth,  which  is  left  blanched  by 
contracted  capillaries,  in  striking  contrast  with  the  scarlet  flush  of  the  rest  of 
tiie  face.  The  white  line  about  the  month  and  the  apparent  bleaching  of  the 
chin  make  the  diagnosis  easy  as  between  this  disease  and  measles  or  small-pox. 
Seen  at  some  distance,  the  eruption  appears  uniform,  but  close  inspection  shows 
it  to  be  punctate  with  confluent  halo  ;  yet,  though  confluent,  there  are  here  and 
there  lines  or  spaces  of  unaffected  surface.  This  marbled  appearance  of  the 
skin  is  very  characteristic,  and  is  due  to  the  intense  irritability  of  the  vaso- 
motor nerves,  which  show  paralytic  dilatations  and  spasmodic  contractions  in 
the  same  sets  of  capillaries.  The  deeply-colored  skin  is  bleached  out  by  pres- 
sure in  lines  or  surfaces,  so  that  figures  or  letters  may  be  inscribed  upon  the 
surface  with  a  vividness  equalled  in  no  other  disease. 

The  color  is  scarlet,  that  bright  red  which  is  designated  by  this  hue,  in 
striking  contrast  to  the  duskier  red  of  measles.  The  Germans  speak  of  the 
crushed-rasj)berry  color  of  scarlatina  as  distinct  from  the  mulberry  hue  of 
measles.  The  shade  becomes  darker,  however,  in  bad  cases  or  especially 
under  defective  hygiene,  when  it  may  be  substituted  by  haemorrhage  itself.  In 
a  pronounced  case  the  affected  skin  is  more  or  less  oedematous.  The  eruption 
lasts  from  four  to  six  days,  extending  meantime  over  the  body,  but  with  less 
luiiformity  over  the  extremities,  where  it  may  show  itself  only  in  blotches  or 
jiatches.  It  begins  to  fade  in  the  order  of  its  appearance,  first  from  the  face, 
neck,  and  chest,  later  over  the  body,  and  disappears  with  a  desquamation  or 
exfoliation  of  the  skin  which  constitutes  one  of  the  peculiar  features  of  the 
disease.  From  regions  covered  by  a  thick  epidermis,  the  hands  and  feet,  more 
or  less  perfect  casts,  epidermic  gloves  and  stockings,  may  be  detached.  More 
or  less  perfect  specimens  of  this  kind  are  to  be  found  in  the  museums.  The 
desquamation  begins  usually  on  the  sixth  day.  It  may  in  a  mild  case  be 
fiirfuraceous.  It  may,  indeed,  be  absent  altogether,  but  it  is  usually,  as  stated, 
membranous  or  lamellar,  the  skin  peeling  ofif'  in  strips  and  flakes.  The  pro- 
cess may  be  repeated  several  times  during  the  course  of  the  disease,  to  form  at 


COURSE    OF    THE   DLSEASE.  217 

times  an  iuteresting  diversion  or  an  annoying  occupation  of  convalescence.  It 
is  impossible  to  overrate  the  value  of  this  process  of  desquamation.  It  con- 
firms the  diagnosis  in  a  doubtful  case;  it  establishes  the  pre-existence  of  the 
disease;  it  reveals  the  nature  of  a  meningitis,  rheumatism,  an  car  disease,  or 
nejihritis  which  has  suddenly  or  insidiously  developed. 

The  sore  throat  is  one  of  the  cardinal  symptoms  of  the  disease.  It  pre- 
cedes the  eruption,  as  has  been  said,  and  constitutes  at  times  an  overshadowing 
symptom.  Suspicion  is  excited  of  the  existence  of  scarlatina  by  the  fact  that 
the  child  complains  of  the  throat,  and  it  is  seen  that  there  is  some  hesitation 
or  difficulty  with  deglutition.  The  act  of  swallowing  is  marked  by  an 
expression  of  pain,  by  the  appliciition  of  the  hands  to  the  neck,  sometimes — 
or,  as  a  rule,  later  in  the  course  of  the  disease — bv  reiruriritation  of  fiuiils 
through  the  nose.  In  many  cases  an  inspection  of  the  throat  discloses  at  a 
glance  the  true  character  of  the  disease.  As  a  rule,  the  sore  throat  of  scarla- 
tina differs  in  no  way  at  first  from  that  of  a  simple  catarrh.  There  is  redness, 
dryness,  and  swelling.  The  mucosa  is  puffed  or  glazed,  esj)ccially  about  the 
soft  palate  and  uvula.  The  glands  of  the  neck  become  swollen  and  tender. 
Diphtheritic  patches,  often  gangrenous  sores,  may  apjicar  later,  while  an 
extensive  interglandular  cellulitis  may  swell  the  neck  to  such  degree  as  to 
obliterate  its  natural  outlines.  It  is,  therefore,  not  at  all  strange  that  scarla- 
tina is  often  confounded  with  diphtheria.  It  is  to  be  remarked,  however,  that 
no  individual  symptom  shows  such  variation  of  intensity  as  the  angina. 
Throat  symptoms  may  be  so  mild  as  to  be  detected  only  on  close  inspcctit)n 
(scarlatina  simplex  or  sine  angina),  or  so  severe,  as  said,  as  to  overshadow  all 
other  signs  (scarlatina  anginosa  of  the  older  writers).  It  is  now  no  longer  an 
unsettled  question  whether  the  diphtheritic  exudations  which  occur  in  grave 
cases  belong  intrinsically  to  scarlatina  or  to  a  complicating  diphtheria.  It  was 
maintained,  on  the  one  hand,  that  the  fidse  membrane  of  scarlatina  ditfcrcd  - 
essentially  from  that  of  diphtheria,  and,  on  the  other,  that  the  inflamuiation 
of  scarlatina  renders  the  individual  more  susceptible  to  an  attack  of  dij))!- 
theria.  The  view  now  prevails  that  the  membrane  is  primary,  that  it  belongs 
to  scarlatina,  and  that  it  may  in  the  vast  majority  of  cases  W  dilfcrcntiatcd 
from  that  of  diphtheria. 

Among  the  disturbances  of  the  digestive  organs  common  t(»  all  the  infec- 
tions, the  condition  of  the  tongue  is  peculiar  in  scarlatina.  The  tongue  is 
coated  white  and  studded  with  red  spots,  tlie  protruding  swollen  pa|»illje,  to 
constitute  what  is  known  as  the  strawberry  or  midberry  tongue.  While  this 
condition  is  not* absolutely  peculiar  to  scarlatina,  it  occurs  in  it  inneli  more  lic- 
quently  than  in  any  other  affection,  and  from  its  obtni>ivcne^s  is  regarded  as 
a  sign  of  much  value.  It  is  unfortunately  not  always  present,  but  when  pres- 
ent it  should  excite  at  once  suspicion  of  the  existeu d'  this  disease. 

Scarlet  fever  shows  predilection  lor  three  <.i<::nis  besides  flic  skin  and 
tJiroat — namely,  the  ear,  tin;  joints,  an<l  the  kidneys,  'i'lie  way  is  o|.en  to 
invasion  of  the  ear  from  the  liiroat  tlin.n-h  the  Kiistaehian  tube.  So  scarla- 
tina is  the   most   fertile  source  of  earache,  otitis   ni<'(li:i,  and   ot(.rrli(ea.     The 


218  SCARLATINA. 

membrane  of  the  drum  is  seen  to  be  intensely  reddened  on  inspection,  or  it 
may  be  paler  and  pushed  outward  by  a  fluid  pent  up  within  the  drum-cavity. 
Voss  calls  attention  to  the  close  association  that  exists  between  certain  cases 
of  ear  disease  and  nephritis.  Tiie  deafness  and  pain  which  announce  this 
complication  often  stand  in  relation  to  the  secretion  of  urine.  They  speedily 
disappear  with  diuresis  and  resolution  of  the  nephritis.  Under  the  persistent 
diminution  of  the  quantity  of  urine  and  continued  albuminuria  the  hyperaemia 
of  the  drum-cavity  quickly  progresses  to  exudation,  redness,  and  swelling  of 
the  membrane  of  the  drum,  which  is  perforated  to  give  vent  to  a  serous,  later 
a  sero-purulent,  discharge.  Frequent  inspection  of  the  ear  should  be  made  in 
the  management  of  every  case  of  scarlatina.  Many  ear  complications  set  in  so 
insidiously  as  to  be  recognized  only  after  irreparable  mischief  has  been  done. 

The  prognosis  of  the  ear  affection  depends  largely  upon  the  period  of  its 
recognition,  for  most  cases  terminate  favorably  if  treated  before  serious  lesion 
has  occurred.  This  treatment  has  reference  here  not  only  to  the  local  affection, 
but  also  to  the  action  of  the  kidneys,  so  that  the  early  recognition  and  appro- 
priate treatment  of  nephritis  may  prevent  many  cases  of  ear  disease. 

From  the  cavity  of  the  drum  to  the  dura  and  pia  mater  the  way  is  often 
open.  Affections  of  the  ear  constitute  by  far  the  most  fruitful  cause  of 
lepto-meningitis.  Of  these  affections,  chronic  suppurative  inflammations  of 
the  tympanic  cavity,  which  result  chiefly  from  scarlatina,  and  which  consti- 
tute over  20  per  cent,  of  all  diseases  of  the  ear,  most  frequently  lead  to  men- 
ingitis through  caries  of  the  osseous  roof  of  the  tympanum.  A  mere  micro- 
scopic breach  in  the  thin  wall  of  bone  that  forms  the  upper  covering  of  the 
tympanic  cavity  will  bring  pus  from  the  tympanum  to  the  dura.  The  roof 
of  the  tympanum  is  composed,  at  best,  of  an  excessively  thin  plate  of  bone, 
which  is  at  times  congenitally  defective,  so  that  in  the  young  a  fold  of  the  dura 
often  pushes  itself  directly  into  the  cavity  of  the  tympanum.  Every  menin- 
gitis whose  cause  is  not  obvious  should  excite  the  suspicion  of  ear  disease, 
which  may  reveal  itself  to  the  sense  of  smell  in  an  offensive  odor  before  the 
appearance,  or  in  the  absence,  of  visible  discharge ;  and  every  case  of  otitis  or 
otorrhoea  in  the  course  of  scarlatina  calls  for  warning  as  to  the  remote  dangers 
of  its  neglect. 

Affection  of  the  joints  is  much  more  uncommon,  but  there  occurs  in  cer- 
tain cases  or  certain  epidemics  a  peculiar  scarlatinal  rheumatism  affecting 
chiefly  the  larger  joints,  ankle,  wrist,  elbow,  and  knee.  The  affection  runs 
usually  a  mild  and  short  course,  but  may,  milike  true  rheumatism,  result  in 
suppuration  or  leave  permanent  deformity.  The  joint  affection  is  probably 
to  be  referred  in  these  cases  to  a  mixed  septic  or  ])yogenic  infection. 

Of  all  the  signs,  complications,  or  sequelae  connected  with  scarlatina,  no  one 
assumes  such  prominence  and  importance  as  the  affection  of  the  kidneys.  Scar- 
latina is  said  to  be  the  mother  of  acute  nephritis.  Aside  from  the  transitory 
albuminuria  which  may  attend  any  high  fever,  disease  of  the  kidneys  is  com- 
paratively frequent.  Epidemics  are  distinguished  from  each  other  in  this 
regard  with  entire  or  comj)aratiye  absence  and  frequency  of  this  complication. 


COURSE    OF    THE    DISEASE.  21 D 

Bartels  declares  that  it  occurred,  in  185:3-54,  22  times  in  180  cases;  in  18();>, 
13  times  in  84  cases,  and  in  other  epidemics  not  once  in  100  cases.  The 
severity  of  the  individual  case  or  of  the  epidemic  does  not  necessarily  indicate 
the  probability  of  nephritis.  It  cannot  be  saitl  that  early  ex))osure  as  to  cold 
predisposes  to  it.  It  may  not  be  ascribed  to  the  atlection  of  the  skin,  as  no 
such  sequel  follows  small-pt)X  with  its  much  more  destructive  lesions.  Kverv 
case  marked  by  high  temperature  shows,  as  stated,  some  albuminuria,  but  the 
albuminuria  which  excites  apprehension  is  that  which  appears  not  at  tin- 
height,  but  in  the  later  course  of  the  disease — at  the  end  of  the  third  week, 
after  the  disease  proper  and  during  convalescence.  Strictly  speaking,  the 
process,  is  therefore,  a  post-scarlatinal  ne|>hritis.  It  sets  in  on  the  tenth  to 
the  thirty-first,  on  the  average  in  twenty  days,  after  the  first  show  of  the 
rash.  It  is  an  acute  parenchymatous  process,  from  which  the  jxitient  recovers 
or  succumbs  quickly,  very  rarely  developing  into  chronic  Bright's  disease.  It 
is  announced  often  by  nervous  symptoms,  headache,  neuralgia,  vertigo,  insom- 
nia, restlessness,  blindness,  convulsion,  or  coma.  Puftiness  of  the  eyes,  any 
local  oedema,  or  dropsy  should  excite  suspicion  of  its  presence. 

Sweeting  showed  by  statistics  that  albuminuria  stood  in  direct  relation  to 
crowd-poisoning,  so  that  the  percentage  of  cases  was  in  direct  ratio  to  their 
number.  Thus,  in  1882,  when  the  hospital  ward  contained  but  64  patients, 
the  percentage  of  albuminuria  was  14,  while  in  1887,  when  it  contained  104(1, 
the  percentage  increased  to  34.9.  It  is  questionable,  however,  whether  this 
albuminuria  may  be  regarded  as  evidence  of  the  true  scarlatinal  nephritis, 
which  depends  more,  as  stated,  upon  the  character  of  individual  cpiilcmics. 
Thus,  Barthez  found  80  per  cent.,  Friedreich  but  4  per  cent.,  of  cases.  It 
must,  however,  be  admitted  that  the  albuminuria  which  attends  cases  of  high 
fever  is  often  the  origin  of  a  later  nephritis.  The  typical  nephritis  ]>resents, 
as  a  rule,  a  picture  very  different  from  that  of  ordinary  albuminuria.  It  dis- 
tinguishes itself  by  the  gravity  of  the  nervous  symptoms,  by  the  extent  oft  lie 
dropsies,  as  well  as  by  the  marked  changes — presence  of  blood,  reduction  in 
quantity,  even  to  anuria,  etc. — in  the  urine.  It  distinguishes  itself  further  by 
the  fact  that  even  the  gravest  symptoms  do  not  jiredude  recovery. 

A  not  infrequent  sign  to  announce  the  advent  of  tlir  true  nephritis  is 
vomiting.  Vomiting  without  cause,  especially  ii"  rciM'aicd  several  times, 
should  excite  suspicion.  The  patient  is  fi)und  pallid  or  there  is  a  du>ky  line 
about  the  face.  On  inspection  of  the  body  it  is  seen  that  there  is  cedeiiKi.  It 
may  be  observed  first  about  the  loins,  but  is,  as  a  ml.',  noiieed  first  under  the 
eyelids.  It  appears  soon  about  the  ll'ct  and  in  the  sidx'utaneous  coimeetivc 
tissue  generally.  The  redema  becomes  an  anasarea  extending  over  the  body, 
and  shows  such  degree  of  distension  as  is  hardly  e.|iialled  in  any  other  (IJmmm'. 
The  hvdrops  invades  also  the  serous  cavities,  the  |.l(nr:e,  perilniieimi.  ;iihI  j..  ri- 
cardium.  Effusions  here  may  be  fiital  l-y  mere  meeh:ini.;il  pre<-Mre.  There 
may  be  superadded  new  or  mixed  inCeetious  elements  to  e.,ni:iniiii:it.-  the  elear 
serum  with  pn-  or  blood.  Severe  cases  begin  with  te,np,.tii.ms  signs— ehill 
with  rapidly  rising  temperature,  vomiting,  hnnbnr  pMiii,  headaehe,  aMiaurosis, 


220  SCARLATINA. 

convulsion,  delirium,  stupor,  coma — and  such  cases  may  terminate  in  a  few 
hours.  Usually,  however,  the  outlook  is  not  so  bad,  and  even  in  the  presence 
of  grave  ursemic  symptoms  the  prognosis  is  not  necessarily  fatal. 

It  is  upon  the  condition  of  the  urine  that  the  recognition  of  nephritis  really 
rests.  The  disease  is  an  acute  parenchymatous  nephritis.  It  begins,  as  stated, 
insidiously  or  suddenly,  and,  as  also  stated,  late  in  the  course  of  the  disease. 
This  late  beginning  is,  however,  really  only  apparent.  The  fact  is,  the 
nephritis  begins  early  and  develops  itself  insidiously  until  it  has  attained  an 
extent  sufficient  to  show  signs. 

Scarlatinal  nephritis  may  be  divided  into  two  periods,  in  the  first  of  which 
there  is  a  diminution  in  the  quantity  of  urine,  albuminuria,  and  some  of  the 
general  symptoms  mentioned.  The  second  period  is  distinguished  by  hsema- 
turia,  with  the  discharge  of  formed  elements,  granular  and  epithelial  casts, 
also  with  an  increase  in  the  quantity  of  urine  and  diminution  of  the  general 
signs,  so  that  should  the  urine  become  more  abundant,  contain  more  blood, 
and  exhibit  formed  elements,  though  grave  symptoms  may  still  shoM'  them- 
selves for  a  time,  the  worst  is  over,  and,  as  S5rensen  puts  it,  "  the  kidneys  are 
beginning  to  free  themselves  of  the  disease."  Perhaps  the  most  grave  single 
symptom  of  nephritis  is  anuria,  but  even  long-continued  anuria  is  not  incom- 
patible with  recovery.  While  it  may  be  said  that  the  gravity  of  the  case  cor- 
responds in  a  general  way  with  the  degree  of  oliguria  or  the  duration  of  anuria, 
there  need  never  be  despair  as  to  the  possibility  of  recovery,  as  Whitelaw  re- 
ported a  recovery  after  a  total  absence  of  urine  for  twenty-five  days.  As  a 
rule,  it  may  be  said  that  the  blood  and  albumin  disappear  in  mild  cases,  and 
the  patient  entirely  recovers  from  the  nephritis  in  two  to  three  weeks. 

Varieties  of  Scarlatina.  —  Besides  the  typical  form  described,  scarlatina 
fallows  itself  in  variation  as  follows  :  1st.  Abortive,  in  which  the  eruption  dis- 
appears after  a  short  duration  without,  or  with  very  mild,  throat  symptoms, 
but  usually  with  lamellar  desquamation  and  sometimes  with  subsequent 
nephritis.  2il.  Fulminant,  in  which  the  patient  is  killed  by  the  poison 
of  the  disease  before  the  period  of  eruption.  3d.  Anginose,  in  which  throat 
symj)toms  predominate.  4th.  Malignant,  with  the  datua  typhosus,  in  which 
all  symptoms  are  intense,  and  haemorrhage  may  occur  su])erficially  from  the 
various  mucosse  or  into  the  skin,  or  with  rapid  collapse  after  signs  of  a  cholera 
morbus.  In  some  very  exceptional  instances  of  undoubted  scarlatina  the  erup- 
tion is  entirely  wanting,  throat  symptoms  only  being  present.  In  these  cases 
careful  inspection  will  usually  disclose  some  eruption  on  covered  parts,  espe- 
cially on  the  posterior  aspect  of  the  bod}-.  It  may  be  seen  at  times  on  or  over 
any  part  of  the  body  immediately  after  death  in  fulminant  forms. 

True  diphtheria  may  coincide  with  or  follow  scarlatina ;  much  more  fre- 
quently, as  a  rule,  the  membrane  which  forms  in  the  throat  is  sid  generis. 
The  membranous  angina  or  pseudo-diphtheria  of  scarlatina  is  much  less 
amenable  to  treatment  than  true  diphtheria. 

Relapse  must  l)e  distinguished  from  second  attack  or  recurrence.  Such 
cases  only  should  be  considered  as  relapses  where  the  fever  and  the  eruption 


DJAOyO^SIS.  '  221 

more  or  less  immediately  follow  the  first  attack,  as  in  the  course  oi'  typhoiil 
fever.  Recurrence  or  second  attack  is,  as  stated,  vei-y  vmw  One  attack  gives 
immunity,  as  a  rule,  for  life.  A  relapse  occurs  before  there  can  he  any  (|Uos- 
tion  or  consideration  of  immunity  as  a  result  of  reabsorj)tion  of  toxic  matter 
from  the  throat  or  wherever  lodged.  Thomas,  who  studied  this  suliject  most 
thoroughly,  admits  a  relapse  not  later  than  four  or  five  weeks  after  the  first 
attack.  The  disease  repeats  itself  in  relapse  in  all  its  details,  and  for  the  most 
part  in  equal  severity.  Shoidd  they  vary  in  severity,  the  second  attack  is 
apt  to  be  the  less  than  the  more  severe.  At  times  it  is  only  rudimentai-y. 
Notwithstanding  the  renewed  infection,  relapses  have,  as  a  ride,  a  more  i'avor- 
able  prognosis. 

Diagnosis. — The  diagnosis  rests  upon  —  1st,  the  absence  of  previous 
attack;  2d,  the  existence  of  other  cases;  3d,  the  short  period  of  iiicui)ation, 
one  to  seven  days  as  a  rule;  4th,  the  violence  of  the  invasion,  csjiecially  the 
occurrence  of  unprovoked  vomiting  (80  per  cent,  of  cases)  and  the  nci-vous 
symptoms;  5th,  the  early  appearance  (second  day)  of  the  eruption,  which 
shows  itself  first  usually  about  the  clavicles,  is  scarlet-colored,  diifusc,  but 
punctate  upon  close  inspection — in  its  disposition  about  the  face,  connnonly 
sparing  the  mouth,  showing  in  vivid  contrast  the  blanched  lips  and  the  blazing 
cheeks  ;  6th,  the  strawberry  tongue  ;  7th,  the  early  ajijicarancc  of  throat  symp- 
toms, Avith  glandular  enlargements  in  the  neck  ;  8th,  the  lamellar  desquama- 
tion;   9th,  the  ear  complications;   10th,  nephritis. 

In  very   mild,  sjioradic,  or  anomalous  cases  the  diagnosis  may  be  deter- 
mined only  by  desquamation,  conq)licati()ns,  or  sequelfc. 

Scarlatina  is  differentiated  from  measles  by  knowledge  of  previous  attacks 
of  either,  of  the  existence  of  other  cases  of  either,  especially  in  the  same  family, 
neighborhood,  or  school ;  by  the  longer  incubation  of  measles  when  the  p.riod 
of  exposure  may  be  (exceptionally)  known  ;  by  the  coryza  wJiicii  pi-eccdes  the 
eruption  of  measles,  and  the  angina  that  of  scarlatina  ;  by  the  shorter  or  more 
intense  invasion  of  scarlatina  with  vomiting  and  sharp  nervous  symptoms  not 
so  common  in  measles;  by  the  time  of  appearance  of  the  crui>tion,  twcnty-fi)ur 
to  fortv-eight  hours  after  initial  chill  or  vomiting  in  scarlatina,  four  days  in 
measle<;  by  the  color,  character,  disposition,  and  duration  of  the  orui.tion, 
dark  red,  aggregated  in  patches,  and  disappearing  in  two  to  four  days  in 
measles,  scarlet-colored,  punctate,  diffuse  over  the  chest  and  face,  sparing  the 
month,  disa])pearing  in  eight  days  or  more  in  scarlatina  ;  by  the  eonqilications 
or  sequela?— bronchitis,  catarrhal  pnemncmia  in  measles,  joint  and  ear  alfcc- 
tions,  nephritis  in  scarlatina;  by  the  desquamnti..n,  usiially  branny  in  measles, 

mend)ranous  in  scarlatina. 

Scarlatina  is  differentiated  from  rubella  (rolheln)  by  the  h.nger  incubation 
or  shorter  or  absent  stage  <.r  invasion;  bv  the  <larker-.-ol<.red  an.!  slmrler 
duration  of  the  eniplion  of  nib<.lla  ;  by  the  asso.-iat..  eatarrh  ot  the  n..se  and 
eves  in  rubella  (absent  in  scarlatina);  by  the  n,.,.],  n>ore  sev.-n-  faue.al  ndlam- 
mation  and  gland  implieation  in  scarlatina;  by  Hir  inn<4.  nulder  ehara..(er  and 
shorter  diu'atiou  oi'  rubella. 


222  SCARLATINA. 

Septicaemia  and  pyaemia  show,  with  the  history  of  a  cause,  successive  chills, 
irrecrular  temperature,  efflorescences  in  appearance  and  in  order  of  distribution 
quite  different  from  the  eruption  of  scarlatina,  more  marked  enlargement  of 
tiie  liver  and  spleen,  more  common  general  affections,  metastatic  processes,  and 
a  lono-er  duration.  Ervthema  shows  a  diffuse  rather  dark  redness  without 
points  or  desquamation,  though  sometimes  with  a  light  furfuraceous  desqua- 
mation, with  absent  or  but  very  slight  fever  (up  to  100°  F.),  has  neither  the 
throat  symptoms  nor  com})lications  of  scarlatina,  and  disappears  in  a  few  days. 
Drug  eruptions,  copaiba,  cubebs,  and  antipyretics,  have  a  history  of  administra- 
tion, no  fever,  and  no  complications. 

Scarlatina  differs  from  diphtheria  in  its  cause.  At  least  it  may  be  said  that 
the  cause  of  diphtheria  has  been  now  quite  definitely  determined,  and  that, 
while  the  same  cause  is  not  to  be  found  in  unmistakable  cases  of  scarlatina, 
it  must  be  held  in  mind  that  the  diseases,  as  stated,  may  coincide,  and  that 
either  mav  be  a  sequel  to  the  other.  These  things,  however,  are  exceptional, 
the  rule  being  that  the  diseases  exist  alone,  and  that,  as  stated,  the  exudation 
of  scarlatina  is  not  that  of  diphtheria,  but  is  sui  generis. 

Clinically,  the  affections  differ  as  follows:  The  false  membrane  appears  at 
once  in  diphtheria,  later  in  the  course  (three  to  five  days)  of  scarlatina.  It 
shows  itself  in  nearly  all  cases  of  diphtheria,  but  in  only  severe  cases  of  scar- 
latina— namely,  such  as  are  marked  by  high  fever,  delirium,  etc.  at  the  start. 
It  shows  a  preference  after  the  pharynx  for  the  lar^aix  in  diphtheria,  and  for 
tiie  upper  respiratory  passages  in  scarlatina.  In  connection  with  it  suppura- 
tion of  the  cervical  glands  and  affections  of  the  ear  are  frequent  in  scarlatina, 
rarer  in  diphtheria.  The  interglandular  connective  tissue  is  indurated  in 
scarlatina  and  only  cedematous  in  diphtheria.  Paralysis,  which  is  frequent  in 
or  after  diphtheria,  is  almost  unknown  in  scarlatina.  On  the  other  hand,  ne- 
phritis, a  frequent  sequel  of  scarlatina,  is  very  rare  after  dijihtheria.  Lastly, 
as  stated,  treatment  has  much  less  effect  on  the  membrane  of  scarlatina.  For 
all  these  reasons  it  is  proposed  by  good  clinicians  to  abandon  the  use  of  the 
term  "diphtheritic"  in  scarlet  fever,  and  to  designate  such  cases  as  mem- 
branous scarlatinal  anginas. 

Coin])lications. — Scarlatina  distinguishes  itself  by  the  intensity  of  its 
j)oison.  It  is  therefore  natural  to  expect  to  find  frequent  and  various  compli- 
cations. Perhaps  there  is  no  disease  in  which  complications  are  so  many  and 
manifold.  The  gravest  are  those  which  affect  the  brain.  The  disease  sets  in 
with  symptoms  of  shock,  with  profound  prostration,  with  delirium,  convul- 
sions, and  coma,  and  these  accidents  may  occur  at  any  time  in  the  course  of 
the  disease.  They  may  be  due,  in  the  first  place,  to  direct  effect  of  the  poison 
upon  the  nervous  system.  They  may  be  the  effects  of  septicaemia  or  of  sup- 
])urative  processes  about  the  throat  and  neck.  They  may  be  due  to  mechan- 
ical ])rcssure  of  the  swollen  tissues  upon  the  great  vessels  in  the  neck,  thus 
interfering  with  the  circulation  in  the  brain.  They  may  be  due  to  meningitis, 
or,  finally,  they  may  be  due  to  kidney  disease. 

The  nervous  symptoms  which  are  due  to  direct  intoxication  are,  as  a  rule, 


COMPLICATIOXS.  223 

the  most  intense.  They  most  diroetly  and  frequently  threaten  and  take  life. 
They  inspire  the  dread  of  the  disease.  These  severe  nervous  symptoms,  inclie- 
ative  of  fresh  influx  or  inundation  of  the  poison,  not  infrequently  precede  the 
eruption,  or,  occurring  after  the  eruption,  even  in  its  full  ettloreseeuee,  cause  it 
to  quickly  fade  away.  These  are  the  eib<es  in  which  the  eruption  is  said  to 
'^  strike  in."  The  people  understand  the  significance  of  the  subsidence  or  dis- 
appearance of  the  eruption.  It  is  often  found  to  occur  simultaneouslv  with  a 
sudden  elevation  of  temperature  to  105°  or  107°.  General  symptoms  or  evi- 
dence of  septicaemia,  meningitis,  endocarditis,  etc.  may  appear  upon  the  same 
or  the  following  day  to  account  for  the  change.  It  is,  however,  an  out i rely 
erroneous  view  to  ascribe  these  changes  to  the  subsideuce  or  tlisappca ranee  of 
the  eruption.  The  disappearance  of  the  eruption  is  to  be  interpreted  as  a 
coeffect  of  the  more  severe  poisoning  of  the  blood,  or  it  is  to  be  attributed  at 
times  to  a  mixed  infection,  as  to  invasion  by  the  micro-organisms  of  pus. 

So,  too,  under  these  circumstances  the  eruption  may  entirely  change  its 
character,  lose  its  individuality,  and  become  hemorrhagic.  This  change  is 
observed,  however,  in  scarlatina  very  much  less  frequently  than  in  measles. 
The  danger  in  scarlatina  is  on  the  part  of  the  brain  and  the  kidneys,  and  the 
secondary  affections  which  occur  in  its  course  are  due  mainly  to  suppurative 
processes  which  display  themselves  rather  in  metastatic  abscesses,  and  more 
es])ecially  in  affections  of  the  serous  membranes. 

Complications  on  the  part  of  the  ear  belong  almost  naturally  to  scarlatina, 
and  result  from  simple  extension  of  the  infectious  process  lioin  the  throat. 
Allusion  has  been  already  made  to  the  changes  which  take  place  iu  the  drum- 
cavity  in  the  course  of  the  disease.  In  certain  cases  these  changes  assume 
prominence,  so  that  the  inflammation  about  the  ear,  exudative  processes,  sup- 
purations, involvement  of  the  mastoid  sinuses,  direct  attention  especially  to  this 
organ.  Implication  of  the  ear  is  usually  earliest  announced  by  earache,  ring- 
ing in  the  ear,  and  deafness.  Next  to  cerebro-spinal  meningitis,  scarlet  fever 
is  the  most  fruitfid  source  or  cause  of  deafness,  and  the  comlitiou  of  the  ear  is 
watched  with  solicitude  throughout  the  course  of  the  disease,  that  treatment — 
and,  if  necessary,  operative  interference — may  be  resorted  to  before  irre])arablc 
damao-e  has  been  done.  Where  any  history  of  aural  aflection  is  wanting  or 
inspection  may  show  no  change,  an  insidiously  developed  otorrhoea  may 
make  itself  manifest,  as  stated,  to  the  sense  of  smell. 

The  complication  on  the  part  of  the  brain  which  results  from  extension 
from  the  ear  as  a  Icpto-meningitis  has  been  suflicicntly  noticed.  It  may  be 
said  that  meningitis  is  observed  more  frequently  as  a  .seciucl  than  as  a  (•«.nq)li- 
cation  in  scarlatina,  but  it  remains  true  that  scarlatina  is  (he  most  fnupicnt 
can.se  of  simple  non-specific  meningitis. 

The  eye  is  seldom  affected  by  .scarlatina.  There  is  rarely  such  a  degree  of 
coryza  as  to  make  the  disease  simulate  m.-asies.  In  exceptional  .-ascs,  more 
especially  in  tuberculous  .subjects,  there  may  (.ceur  keratitis  and  kerat..-mala- 
cin,  or  even  panoi)htlialmitis,  with  destrncti(»n  of  the  globe. 

The  kidney  di.sea.se  may  cau.se  amaurosis,  which  di.^apjx'ars,  as  a  rule,  a? 


IS 


224  SCA  RLA  TINA . 

suddenly  as  it  sets  in,  or  albuminuric  retinitis,  which  distinguishes  itself  from 
that  of  other  forms  or  causes  of  kidney  disease  by  its  transitory  character. 

Grave  complication  is  not  infrequently  presented  by  the  intense  inflamma- 
tion about  the  neck.  The  glands,  the  lymph-vessels,  the  interglandular  tis- 
sues, are  swollen  and  amalgamated  into  a  mass  of  board-like  induration  which 
fixes  the  head  to  the  body,  compresses  the  great  vessels,  and  results  not  infre- 
quently in  extensive  suppurations.  Phlegmonous  processes,  gangrenous  de- 
structions, occur  frequently  in  connection  with  diphtheritic  or  pseudo-diphthe- 
ritic deposits  in  the  throat.  The  pressure  may  compress  the  trachea  or  suffocate 
by  oedema  of  the  glottis.  Pus  burrows  down  into  the  chest,  to  at  times  erode 
in  its  course  large  vessels,  to  lead  to  fatal  hseraorrhage,  or  to  destroy  important 
nerves  or  other  structures.  The  inflammation  of  the  throat  may  extend  to 
involve  the  larynx  and  bronchial  tubes.  Pneumonia,  both  bronchial  and 
croupous,  occurs  not  infrequently  in  grave  cases.  Haemorrhage  of  the  lungs, 
gangrene,  more  especially  oedema,  hypostases,  take  life  directly  or  indirectly 
by  over-strain  of  the  heart. 

The  most  frequent  and  fatal  so-called  end  or  terminal  complications  are  the 
affections  of  the  serous  membranes.  Meningitis  heads  the  list,  in  that  it  is 
not  only  the  most  severe,  but  most  early,  of  these  aflections.  It  occurs  at 
times,  as  stated,  almost  with  the  onset  of  the  disease,  so  that  the  separation  of 
this  affection  from  toxic  effects  of  the  blood  upon  the  brain  itself  may  be  dif- 
ficult. In  meningitis  the  headache  becomes  more  intense,  or  recurs  if  it  have 
subsided.  The  special  senses  suffer  extreme  hypersesthesia.  There  is  usually 
evidence  of  affection  of  the  membranes  of  the  spine — opisthotonos,  vomiting, 
convulsions.  The  pleura  is  next  most  frequently  affected.  Scarlatinal  pleur- 
itis  distinguishes  itself,  strange  to  say,  by  its  unilateral  character,  and  differs 
from  pleuritis  from  other  causes  in  the  fact  that  it  so  easily  becomes  purulent. 
Pericarditis  is  usually  so  much  more  rare  as  to  be  generally  overlooked,  while 
endocarditis  is  readily  recognized  by  the  evidence  of  valve  lesions,  hypertro- 
phies, and  embolic  products. 

All  these  various  complications  are  now  known  to  be  due  to  the  micro- 
organisms of  pus,  which,  strictly  speaking,  have  nothing  really  to  do  with  the 
cause  of  scarlatina.  The  cause  of  scarlatina  opens  the  way  for  their  invasion, 
and  these  micro-organisms — or  the  evidence  of  their  invasion — have  been 
traced  directly  from  the  throat  as  their  surface  of  origin. 

Prog-nosis. — The  prognosis  of  scarlatina  varies  greatly,  perhaps  as  in  no 
other  disease.  On  account,  however,  of  the  severity  of  certain  epidemics,  and 
of  the  suddencss  with  which  the  disease  may  assume  gravity  in  any  individual 
case  by  reason  of  its  own  poison  or  by  reason  of  complications,  the  progno- 
sis is  always  grave.  Reimer,  who  studied  the  subject  from  this  standpoint 
most  thoroughly,  says  that  the  prognosis  progresses  from  simj^le,  uncomplicated 
cases  which  have  no  mortality,  through  complicated  cases  of  medium  gravity, 
with  a  mortality  of  25  per  cent.,  up  to  the  severest  cases,  whose  mortality 
reaches  83|-  per  cent.  The  ratio  of  its  gravity  to  other  disease  is  shown  in 
the  difference  in  the  prognosis  of  a  case,  whether  preceded  or  followed  by 


MORBID    A XA  TOM  Y.— PROPHYLAXIS.  225 

scarlet  fever.  These  figures  sliow  tliat  when  scarlet  fever  is  followcil  by  other 
diseases  the  mortality  is  44  per  cent.,  but  when  scarlet  fever  follows  othei-  dis- 
eases the  mortality  is  82  per  cent. 

In  estimating  the  prognosis  it  may  be  said  that  the  pulse,  as  a  rule,  corre- 
sponds to  the  temperature.  Arhythmia  is  usually  a  forerunner  of  complica- 
tions. Grave  nervous  symptoms  are  always  ominous,  as  are  also  extensive 
suppurative  processes.  It  is  not  a  good  sign  for  the  eruption  to  **  sink  in." 
The  complications  on  the  part  of  the  kidneys,  however  severe  the  signs, 
though  grave,  are  never  necessarily  flital.  From  the  gravest  accidents 
recovery  is  still  possible. 

Pneumonia,  pleurisy,  with  its  wonted  suppurative  course,  peritonitis,  often 
of  such  insidious  onset  as  to  have  escaped  detection  at  first,  intensely  aggravate 
the  prognosis.  Peri-  and  endocarditis  are  almost  necessarily  fiital.  An  uiuluo 
protraction  of  the  disease,  by  reason  of  reabsorption  of  products  to  constitute  a 
relapse  or  by  reason  of  complications,  makes  the  prognosis  grave,  in  correspond- 
ence with  the  intensity  of  the  signs,  duration  of  the  disease,  or  character  of  the 
complication.  Some  of  these  cases  succumb  finally  to  atelectasis,  heart  failin-e, 
decubitus,  or  marasmus. 

Morbid  Anatomy. — The  morbid  anatomy  of  scarlatina  is  the  picture  of 
the  infections  in  general  ;  that  is,  the  lesions  encountered  are  those  common  to 
all  the  acute  infections,  among  which  scarlatina  takes  place  according  to  its 
gravity.  The  body  may  or  may  not  show  exanthem.  Usually,  bccausi'  death 
occurs  early,  the  eruption  is  faded  to  a  mere  residue,  or  spots  of  h\i)era?mia 
may  with  difficulty  be  distinguished  from  post-mortem  changes.  There  are 
occasionally  encountered,  as  stated,  the  fulminant  forms,  in  whieh  the  eruption 
never  appears,  or  appears  only  after  death  to  establish  the  nature  of  the  hitherto 
unrecognized  affection.  The  various  stages  of  desquamation  may  be  observed 
along  \yitli  the  changes  produced  by  hydrops  in  cases  wjiere  death  has  oceurrcil 
in  consequence  or  in  the  course  of  renal  disease.  Protracted  cases  \\\\\  show 
emaciation  and  decubitus.  The  blood  is  fluid,  dark,  and  scant  of  fibrin.  The 
clot  is  small,  black,  friable.  The  heart  is  lax  and  flabby.  The  spleen  is 
swollen,  its  pulp  soft  and  red.  The  various  serous  membranes  show 
ecchymoses. 

The  most  persistent  changes  are  seen  about  the  thr(»at.  'i'here  may  be 
slight  evidence  of  hypcrsemia,  though  all  cedema  will  have  subsided.  The 
glands  about  the  neck  remain  enlarged  and  indurated,  to  j)resent  at  times  a 
conglomerate  mass,  at  times,  again,  suppuration,  'i'he  liver  and  kidneys  show 
histological  change  in  swelling  and  opacity  of  their  parenchymatous  structure. 
Inasmuch  as  death  usually  occurs,  as  stated,  early  in  the  history  oC  the  diseaso 
or  as  the  result  of  blood-poisoning  and  nervous  symptoms,  there  is  usually  U\ 
1)6  found  hyperaemia  of  the  brain  and  of  its  membranes,  and  in  <|nitc  fresh 
autopsies  fjedema  of  the  brain. 

Prophylaxis. — Isolation  is  the  only  prophylaxis;  and,  inasnuicli  as  the  area 
of  infection  is  so  closely  circumscribed,  isolation  is  iiiikIi  more  ciVcctivc  in  scar- 
latina than  in  measles  or  small-i)OX.     As,  lioweycr.  tli<'  disease  may  undoubtedly 

Vol..  I.— 15 


226  SCA  BLA  TINA . 

be  carried  by  third  persons,  the  attendants  upon  the  sick  should  not  come  in 
contact  with  unaffected  members  of  the  family.  The  best  protection  is  offered 
by  removal  from  the  house  of  all  children  liable  to — that  is,  unprotected  by 
previous  attack  of — the  disease.  Unaffected  children  remaining  at  home 
should  not  attend  school  or  other  assembly  for  several  weeks  after  perfect 
recovery  of  a  member  of  the  family.  It  is  believed,  whether  it  may  be 
proven  or  not,  that  contagium  emanates  from  the  body  so  long  as  desquama- 
tion continues,  and  the  child  should  not  be  allowed  to  associate  with  its  fellows 
until  the  last  scale  of  skin  has  been  removed.  Desquamation  continues  long- 
est on  the  soles  of  the  feet,  and  inspection  of  these  parts  gives  the  best  answer 
as  to  the  time  when  all  desquamation  shall  have  ceased.  Such  desquamation 
has  been  observed  as  late  as  forty  days  after  the  disappearance  of  the  eruption, 
thougli  it  usually  ceases  entirely  in  less  than  half  that  time. 

Prophylaxis  implies  also  the  destruction  or  thorough  disinfection  of  all 
articles  which  have  come  in  contact,  direct  or  indirect,  with  the  patient.  The 
room  should  be  disinfected,  ceilings  whitened,  walls  rubbed  down  with  bread, 
floors  scrubbed  with  corrosive-sublimate  solutions,  carpets  or  rugs  beaten  and 
sus])ended  in  the  open  air  for  a  long  time,  bedding  and  clothing  boiled,  if  not 
buried  or  burned,  or,  if  preserved,  subjected  when  possible  to  live  steam.  It  is 
a  sad  comment  upon  our  sanitation  that  public  disinfecting  stations  are  not  yet 
established  in  all  our  cities  and  towns.  Prophylaxis  involves  attention  to 
detail.  The  disease  has  been  conveyed  by  letters  sent  out  from  a  sick-room,  by 
cushions  of  chairs,  curtains,  piano-covers,  etc.  Special  attention  must  be  paid 
to  the  discharges,  to  sponges,  cloths,  and  towels  used  in  ablutions.  The  fact  is, 
that  sponges,  handkerchiefs,  etc.  are  best  substituted  by  rags,  Mdiich  may 
be  immediately  destroyed  by  fire.  It  must  not  be  forgotten  that  the  hair  of 
the  head  retains  and  conveys  contagium.  Thorough  ablution  with  soap 
and  water  or  with  the  carbolized  soaps  will  disinfect  the  hair.  The  hair 
of  the  boy  patient  should  be  cut  short.  It  must  be  remembered  that  even  the 
shoes  require  disinfection.  They  may  be  painted  inside  and  out  with  carbolic 
acid  and  glycerin,  equal  parts.  Ventilation  of  the  sick-room  throughout  the 
whole  period  of  the  disease  is  not  only  a  necessity  of  treatment,  but  also  of  dis- 
infection. The  frequent  bathing  of  the  body,  with  the  subsequent  application 
of  some  unctuous  material — cocoa  butter,  lanoline,  vaseline,  etc. — not  only 
gives  great  comfort  to  the  patient,  but  confines  the  poison  to  a  narrower  field. 
After  the  recovery  of  a  patient,  and  more  especially  after  a  death,  outside  win- 
dows should  be  thrown  open  and  the  room  ventilated  for  a  week.  Here,  too, 
attention  must  be  paid  to  detail.  Closet-doors  must  be  opened  and  the  inside 
of  closets  with  their  contents  disinfected  and  ventilated  as  before.  The  fact  is, 
the  city  government  should  take  charge  of  all  such  apartments.  They  should 
be  disinfected  and  ventilated  under  the  inspection  of  health  authorities.  The 
inside  doors  to  halls  and  to  other  rooms  should  be  closed  by  the  seal  of 
authority,  and  the  same  precautions  taken  as  in  the  prevention  of  entrance 
or  interference  in  cases  of  crime.  Scarlet  fever  is  for  the  most  part  spread 
by  ignorance,  by  carelessness,   by  blunders   which    are   worse   than    crimes. 


TREATMENT.  227 

Reference  is  made  here  to  the  premature  return  of  children  to  school  or  the 
constant  attendance  at  school  of  unatiected  cases  in  a  family,  to  contact  in 
street-cars,  railroad-trains,  steamers,  etc.  Parents,  nurses,  and  even  physicians, 
are  all  too  careless  in  this  regard. 

In  the  way  of  drugs  there  is  no  preventive  of  scarlet  fever.  The  claim 
that  a  drug  may  protect  against  the  disease  because  when  administered  it 
produces  a  symptom  which  resembles  that  of  the  disease  is,  in  the  light  of 
our  present  knowledge  regarding  the  infections,  worse  than  mediteval  gibberish 
— worse,  because  it  may  beget  a  false  security  in  reference  to  exposure.  This 
claim  has  been  made  for  belladonna  because  it  flushes  the  face.  It  has  no 
more  foundation  in  fact  than  protection  by  a  blush,  which  has  the  same  effect. 
Belladonna  by  making  a  child  sick  rather  predisposes  to  than  protects  against 
scarlatina. 

The  hope  that  has  been  cherished  regarding  protection  by  vaccination  has 
proven  equally  vain.  Attempts  have  been  made  to  inoculate  certain  disease- 
products  of  animals,  horses,  dogs,  and  rabbits  with  a  view  of  producing  a 
milder  or  modified  form  of  scarlatina.  Claim  has  been  set  up  in  this  direc- 
tion, as  by  Strickler,  who  introduced  the  nasal  mucus  of  horses  supposed  to 
have  been  affected  with  the  disease  into  the  bodies  of  twelve  children,  in  all 
of  whom  it  produced  sores  at  the  point  of  introduction,  with  circiunjaccnt 
inflammation  of  the  skin  and  lymph-glands.  It  was  stated  that  these  children 
thus  inoculated  failed  to  contract  the  disease  after  exposure  to  scarlatina. 
These  experiments  were  made  in  imitation  of  the  first  experiments  of  Jenner 
with  small-pox,  but  the  objections  to  accepting  such  conclusion  arc  numerous 
and  obvious.  In  the  first  place,  it  is  not  known  that  any  of  the  lower  animals 
reallv  suffer  from  scarlatina  or  any  allied  disease.  Secondly,  it  has  not  been 
established  bv  experiment  that  the  disease  which  results  from  the  introduction 
of  scarlatinal  matter  of  man  into  animals  is  really  scarlatina.  Third,  it  could 
not  therefore  be  known  that  matter  taken  from  animals  was  the  product  of  this 
disease.  Fourth,  susceptibility  is  so  much  less  in  scarlatina  that  failure  to 
contract  the  disease  after  exposure  has  not  the  same  weight  as  in  small-pox. 

Treatment. — The  treatment  is  wholly  symptomatic.  The  sick-room 
requires  constant,  thorough  ventilation  from  the  outside  air.  The  tcmin'ra- 
ture  should  be  held  at  from  65°  to  70°  F.,  as  registered  l)y  a  thcrmoni(>tor— 
not  at  the  door,  window,  or  fire,  but  at  the  head  of  the  bed.  An  open  fire  in 
winter  is  preferable  to  any  other  method  of  heating.  The  })atient  shoidd  wear 
a  lon^r  muslin  nidit-dress  without  other  clothing.  Tlie  bed-covering  must  be 
as  light  as  is  consistent  with  comfort. 

Milk  and  meat  soups  make  the  best  diet,  AVatcr,  carbcunted  water,  seltzer, 
apollinaris,  lemonade,  toast-water,  barley-water,  should  be  given  freely  to 
relieve  thirst  and  to  keep  the  kidneys  flushed.  Prink  should  be  protfered 
once  an  hour  in  high  fever  during  the  day. 

The  utmost  cleanliness  is  to  be  maintained  by  frequent  sponging  and  bath- 
ing of  the  surface.  Daily  tepid  baths  (full  length)  give  the  greatest  comf.)rt 
throu.rhout  the  disease.  '  Fev<-r  ab..ve  1<»;;^   F,  is  best  <-ombated   with   cold 


228  SCA RLA  TINA . 

sj3onges,  cold  packs,  or  cold  baths.  Cold  baths  are  most  effective,  but  are 
seldom  practicable  as  yet.  It  is  not  essential  that  the  temperature  be  brought 
down  to  the  nornjal  degree.  A  reduction  of  a  few  degrees  suffices  to  give 
the  patient  comfort,  and  relieves  all  danger  attendant  upon  high  temperatures. 
A  warm  or  tepid  bath  will  reduce  the  temperature  one  or  two  degrees,  and 
patients  solicit  such  bathing  when  the  cold  bath  may  excite  terror.  While 
it  is  true  that  the  temperature  reaches  the  highest  grades  in  scarlatina,  and  the 
patient  suffers  corresponding  discomfort  and  danger,  it  is  not  true  that  the  dan- 
ger is  caused  by  the  fever.  The  danger,  the  discomfort,  and  the  fever  are 
produced  by  a  common  cause — namely,  the  poisoning  of  the  blood ;  and  there 
can  be  no  question  of  radical  therapy  until  after  the  discovery  of  some  agent, 
some  antitoxine,  which  will  neutralize  the  chemical  poison  circulating  in  the 
blood.  It  is  indeed  a  question  if  some  fever  be  not  salutary.  We  combat  the 
fever  in  our  day  more  especially  with  regard  to  the  cocpfort  of  the  patient. 
A  difference  of  two  degrees  makes  great  difference  in  the  feelings  of  the 
patient.  The  reduction  of  high  temperatures  by  cold  bathing  is  attended,  as 
a  rule,  with  diminution  of  discomforts  and  dangers.  The  bath  addresses  the 
cause  indirectly  through  its  effects.  Frequent  bathing  is  the  best  therapy  in 
the  treatment  of  scarlatina  as  of  any  other  infection.  There  may  be  reasons 
which  render  a  bath  impossible.  In  these  cases  resort  must  be  had  to  frequent 
ablutions.  It  may  become  necessary  to  substitute  a  bath  by  drugs,  especially 
in  the  presence  of  other  indications.  Resort  may  then  be  had  to  the  antipy- 
retics. Phenacetin  is  the  least  injurious.  It  may  be  given  to  a  child  in  a 
dose  of  2^  to  5  grains — to  an  adult  in  double  this  dose  once  or  twice  in  the 
course  of  a  day.  It  is  of  especial  value  in  headache  or  other  nervous  distress. 
It  is  best  administered  in  capsule  or  in  powder,  taken  directly  upon  the  tongue 
or  stirred — that  is,  suspended — in  milk,  or,  in  case  of  high  fever  with  dry 
tongue,  floated  upon  the  surface  of  a  teaspoonful  of  water.  Only  in  case  of 
failure  with  phenacetin  should  resort  be  had  to  antipyrine  or  antifebrin,  either 
of  which  must  be  given  in  half  the  dose  of  phenacetin.  Burning  and  itching 
of  the  skin  are  best  allayed  by  application,  after  tepid  baths,  of  vaseline,  cocoa 
butter,  lanoline,  goose-grease,  bacon,  or  fresh  lard.  Quiet,  peaceful,  and  more 
or  less  restorative  sleep  is  wont  to  occur  after  a  bath  and  inunction  in  this  way. 
Nervous  distress,  jactitation,  convulsions,  insomnia,  headache  are  best  com- 
bated by  bromide  of  sodium  in  doses  of  from  5  to  10  grains  to  a  child,  30  to 
40  to  an  adult,  largely  diluted,  or  if  more  obstinate  by  chloral,  5  grains  to  a 
child,  15  grains  to  an  adult.  No  other  single  remedy  gives  the  comforts  of 
chloral  in  repeated  doses  of  2  or  3  grains.  Broken  doses  of  Dover's  powder 
in  grain  doses  to  a  child,  3  to  6  grains  to  an  adult,  may  substitute  it  in  a  suit- 
able case.  Ice-bags  should  be  applied  to  the  head  for  meningeal  symptoms. 
The  vomiting  which  occurs  in  the  inception  of  the  disease  is  often  suf- 
ficiently relieved  by  carbonated  drinks,  the  best  of  which  is  the  German  seltzer 
water,  with  milk  equal  parts,  or  by  lime-water  and  milk  1  :  3,  by  small  doses 
of  bismuth  (5  to  10  grains),  by  the  bicarbonate  of  sodium  in  equal  dose,  or 
by  sips  of  excessively  hot  water.      The  most  powerful  drug  we  possess  is 


TREA  TMENT.  229 

chloral.  The  most  refractory  vomiting,  of  whatever  cause,  will  yield  to  the 
administration  of  a  few  doses  of  from  2  to  5  grains  of  chloral  diluted  in  a 
dessert-  to  a  tahlespoonful  of  pei)permint-water.  Should  the  remedy  be 
rejected  before  it  can  be  absorbed,  it  may  be  introduced  into  the  bowel  in 
double  dose.  It  must  be  a  remarkable  case  to  resist  chloral  in  one  or  other 
of  the  modes  of  use  or  to  justify  resort  at  last  to  a  subcutaneous  injection  of 
morphine. 

Throat  symptoms  call  for  inhalations  of  steam,  best  from  the  steam  vapor- 
izer, simple  or  medicated  with  bicarbonate  of  sodium,  saturated  solution  of  boric 
acid  3  drachms  to  4  ounces,  or  carbolic  acid  J-  a  drachm  to  4  ounces,  or  thymol 
5  grains  to  1  ounce  alcohol  or  3  ounces  of  water,  or  gargles  of  hot  water,  of 
carbolic  acid  15  to  30  drops  to  4  ounces,  perchloride  of  ir(»n  1  drachm  to 
4  ounces,  or  direct  applications  of  carbolic  acid,  with  glycerin  equal  parts, 
bichloride  solutions  from  1  :  1000  to  1  :  100,  or  intraparenchymatous  injec- 
tions (tonsillar)  of  a  few  drops  of  the  carbolic-acid  solution  Ity  means  of  a 
hvpodermic  syringe  with  a  fine  long  aspirator  needle.  Cloths  wrung  out  of 
boiling  water,  applied  about  the  throat  and  covered  in  by  thick  dry  cloth, 
relieve  the  pains  of  extreme  distension. 

Affections  of  the  ear  are  best  treated  by  a  douche  of  hot  water  and  a  Polit- 
zer  inflation  with  air.  Tension  in  the  membrane  of  the  tympanum  may  require 
puncture,  and  suppuration  of  the  mastoid  cells  trcj^hining.  Earache  is  best 
relieved  by  instillation  of  hot  water  or  solutions  of  atro])ine,  1  grain  to  the 
ounce.  Otorrhcea  is  best  treated  by  filling  the  external  canal  with  powdered 
boric  acid  after  thorough  cleansing  with  a  cotton-wrapped  sound,  or  direct 
application  to  accessible  granulations  of  chromic  acid,  London  paste,  or  the 
galvanic  cautery. 

Nephritis  calls  imperatively  for  hot  baths,  under  which  all  the  symptoms 
of  this  complication,  including  vomiting,  are  wont  to  speedily  subside.  The 
bath  must  be  hot  (100°  to  110°  F.) ;  the  patient  must  be  rolled  in  a  blaidvct 
after  it,  and  be  allowed  to  sweat  for  an  hour.  Rheumatism  calls  for  the  sali- 
cylates in  saturating  dose.  Alcohol,  digitalis,  and  nitro-glycerin  may  become 
necessities  in  the  later  course  of  all  grave  cases,  and  may  be  urged  in  over- 
dosao-e.  together  with  other  analeptics— camphor,  ether,  musk — in  the  way  of 
a  "forlorn  hope"  in  fulminant  forms. 


MEASLES. 

By  JAMES  T.  WHITTAKER. 


Synonyms  and  Definition. — Measles  (Sanscrit),  masiira,  masern  (Ger- 
man, spots),  rubeola  (Sauvages),  ruber,  rougeole  (French,  red),  morbilli 
(Italian,  diminutive  of  morbus), — an  intensely  contagious,  acute  infection, 
characterized  by  coryza  and  bronchitis,  a  red  spotted  eruption  with  branny 
desquamation,  fever  of  typical  course,  subsiding  at  efflorescence,  with  liability, 
mostly  as  sequel,  to  catarrhal  pneumonia,  sometimes  to  tuberculosis. 

Ahrun  (Aaron),  a  Christian  priest  and  physician  of  Alexandria  (a.  d.  610- 
641),  is  celebrated  as  having  been,  by  universal  acknowledgment,  the  first 
writer  to  have  mentioned  small-pox  and  measles.  Though  existent  from  time 
immemorial,  measles  was  first  described  by  Rhazes  (900  A.  D.)  in  an  attempt 
to  separate  it  from  small-pox.  Rhazes  noticed  among  the  symptoms  of 
measles  "  redness  of  the  eyes,  with  a  great  flow  of  tears,  nausea,  and  anxiety," 
remarking  also  that  the  measles  "  that  are  green  or  violet-colored  are  of  a  bad 
kind,  especially  if  they  sink  in  suddenly,  for  then  a  swooning  will  come  on 
and  the  patient  will  soon  die." 

The  disease  was  described  under  the  name  hhasbah.  Nearly  all  subsequent 
writers  adopted  the  Italian  term  morbilli  up  to  the  middle  of  the  eighteenth 
century,  when  Sauvages  substituted  for  it  or  re-established  the  term,  said  to 
have  been  first  used  by  Haly  Abbas,  rubeola,  which  the  French  accepted  in 
their  own  equivalent  of  rougeole.  Fagge  laments  the  substitution  of  rubeola 
and  its  adoption  by  later  English  writers,  but  surely  without  cause,  for  mor- 
billi refers  simply  to  the  mildness  of  the  malady — a  fact  to  which  there  are 
many  exceptions.  Morbilli  is,  anyhow,  too  indefinite  to  be  the  name  of  any 
disease.  It  liolds  its  place  only  under  the  sanction  of  antiquity  and  authority. 
Rubeola  means  something  definite.  It  expresses  a  characteristic  feature  of  the 
disease — in  fact,  the  most  characteristic  feature — the  redness  of  the  eruption. 
It  is  unfortunate  that  this  term,  rubeola,  has  been  adopted  by  certain  German 
writers  to  express  that  particular  subv^ariety,  special,  or  hybrid  form  of  dis- 
ease known  as  German  or  French  measles  or  popularly  in  Germany  as  rotheln. 
As  scarlatina  would  seem  by  universal  acce})tance  to  be  the  most  appropriate 
name  for  scarlet  fever,  rubeola  must  be  the  most  appropriate  for  measles. 

Foreest,  the  Dutch  Hippocrates,  in  1565  first  pointed  out  certain  dis- 
tinctions between  measles  and  scarlet  fever,  though  the  separation  of  the  affec- 
tions is  usually  credited  to  Sydenham  (1665),  the  English  Hippocrates. 

Sydenham  described  the  rigors  which  constitute  the  chill  in  the  inception 
2;in 


SYX0NY3fS  Ay  I)    DEFiyiTKJX.  231 

of  the  disease,  and  furnished  an  account  close  and  succinct  enough  to  cutitlr 
him  to  the  position  of  pioneer.     Thus :  "  It  generally  attacks  infants,  and, 
with  them,  runs  through  the  whole  family.     It  begins  with  shivcrings  anil 
shakings,  and  with  an  inequality  of  heat  and  cold  which,  during  the  first  day, 
mutually  succeed  each  other.     By  the  second  day  this  has  terminated  in  a 
genuine   fever,  accompanied  with  general  disorder,  thirst,   want  oi"  appetite, 
white  (but  not  dry)  tongue,  slight  cough,  heaviness  of  the  head  and  eyes,  and 
continued  drowsiness.     Generally  there  is  a  wee})ing  from  the  eyes  and  nos- 
trils;  and  this  epijihora  passes  for  one  of  the  surest  signs  of  the  accession  (tf 
the  complaint.     But  to  this  may  be  added  another  sign  equally  sure — viz.  tlu' 
character  of  the  eruption.     The  patient  sricezes  as  if  from  cold,  his  eyelids  (a 
little  before   the  eruption)  become  pnffy  ;  sometimes  he  vomits;    oftener  lie 
has  a  looseness,  the  stools  being  greenish.     This  last  symptom  is  common- 
est with  infants  teething,  who  {ilso  are  more  cross  than  usual.     The  symptoms 
increase  till  the  fourth  day.     At  that  period  (although  sometimes  a  day  later) 
little  red  spots,  just  like  flea-bites,  begin  to  come  out  on  the  forehead  and  the 
rest  of  the  face.     These  increase  both  in  size  and  nund)cr,  grouj)  themselves 
in   clusters,  and   mark  the  face  with   largish  red   spots  of  ditt'erent  tigures. 
These  red  spots  are  formed  by  small  red  papula-,  thick  set,  and  just  raised 
above  the  level  of  the  skin.     The  fact  that  they  really  protrude  can  scarcely 
be  determined  by  the  eye.    It  can,  however,  be  ascertained  by  feeling  the  sur- 
face with  the  fingers.     From  the  face— where  they  first  appear— the  spots 
spread  downward  to  the  breast  and  belly,  afterward  to  the  thighs  and  li>gs. 
Upon  all  these  parts,  however,  they  appear  as  red  marks  (uily.     T.y  the  eighth 
day  the  spots  have  disappeared  from  the  face  and  show  but  faintly  elsewhere. 
On  the  ninth  day  there  are  no  spots  anywhere.      In   place  thereof,  the  face, 
trunk,  and  limbs  are  all  covered  with  particles  of  loosened  cuticle,  so  that  they 
look  as   if  they   had   been   ])owdcred  over  with   Wowv,  since  the  particles  of 
broken  cuticle  are  slightly  raised,  scarcely  Ik.UI  together,  and,  as  the  disease 
goes  off,  peel  off  in  small  particles  and  fall  from  the  whole  of  the  b..dy  in  (he 

form  of  scales." 

The  primeval  home  of  measles  is  unknown.  From  its  earliest  reiM.gnitinn 
it  has  prevailed  in  epidemic  form  in  Asia,  Furope,  and  South  America.  It 
was  imported  to  the  United  States  with  the  first  settlers,  to  gradually  spread 
over  it  with  -the  march  of  the  pioneers.  It  reached  Oregon  in  182!),  Cali- 
fornia and  Hudson's  Bav  in  1846,  the  Sandwich  Islands  in  1848,  when.c  .t 
was  carried  to  Australia  in  18o4,  Grcenlan<l  in  1S<;  I.  Though  tl..^  .hMa-e  l.a^ 
now  become  indigenous  everywhere  an.l  individual  eas(>s  arc  ol  .ontumal 
occurrence  in  large  cities,  measles  usually  prevails  as  an  («pi<lemi.-  <.v.'r  a  wi.lc 
extent  of  country,  with  intervening  periods  of  abs..n<-<..  Kpxlemics  .!.<•  out  m 
two  or  three  months  from  lack  of  nialciak  Measles  does  not  Imld  ..v.r  u. 
sporadic  cases  like  scarlatina,  but  <lisa|.pear8  completely,  to  reapp....-  with  na.- 
cumulation  of  material  evcrv  three  or  four  years. 

Measles   is   a   disease   which    is   cliaractcri/e<l    by  siug.dar    nnil..rniiiv    ot 
appearance.      It  has  always  presented  itself  in  exactly  the  >an.c  way  and  will, 


232  MEASLES. 

the  same  signs,  course,  complication,  and  duration  from  its  earliest  recognition. 
It  has  in  it  much  less  of  the  irregular,  capricious,  and  unexpected  than  has 
scarlet  fever.  It  does  not  show  the  sudden  changes,  storms,  and  strokes  of 
lightning  in  the  midst  of  comparative  fair  weather  that  may  occur  in  scarla- 
tina.    Consequently  the  disease  is  by  no  means  so  much  feared. 

As  the  name  indicates,  it  is  considered  a  comparatively  mild  disease,  a 
diminutive  disease.  It  is  the  nature  of  measles,  aside  from  complications  and 
surroundings,  to  be  mild  in  its  course,  but  it  may  assume,  especially  under  bad 
hygiene,  a  malignancy  and  mortality  which  associate  it  with  the  plague  and 
the  worst  forms  of  infection.  The  fact  is,  the  mildness  of  measles  is  over- 
rated, or,  at  least,  is  to  a  great  extent  counterbalanced  by  the  frequency  of  the 
disease  and  the  quality  of  its  complications.  Thus  the  statistics  from  the 
whole  of  Austria  and  Saxony  from  1873-87  show  that  there  died  in  every 
10,000  people  in  Austria  of  measles  27,  of  scarlet  fever  67  ;  in  Saxony  of 
measles  25,  and  of  scarlet  fever  48.  Henoch  quotes  the  mortality  of  measles 
in  Berlin  in  1887  at  0.74,  scarlet  fever  at  0.85  per  cent.  To  get  some  idea  of 
the  respect  which  is  due  to  measles  as  a  malign  disease,  as  one  of  the  veritable 
plagues  of  mankind,  we  must  study  the  record  (Hirsch)  of  its  ravages  in  sav- 
age and  semicivilized  lands.  As  late  as  1749  measles  carried  off  among  the 
aborigines  about  the  Amazon  30,000  people,  whole  tribes  at  a  time ;  in  As- 
toria one-half  of  all  the  inhabitants  fell  victims  to  measles  in  1829;  and  the 
same  proportion  was  observed  among  the  Indians  at  Hudson's  Bay  in  1846, 
the  Hottentots  in  1854,  the  Tasmanians  in  1861,  and  the  Mauritians  in  1874. 
Squire  relates  that  a  frightful  epidemic  of  measles  in  the  Fiji  Islands  car- 
ried off  20,000 — that  is,  nearly  one-ft)urth  of  the  whole  population.  Cruik- 
shank  reports  of  this  attack  that  later  in  the  epidemic,  when  it  was  said  to 
be  like  the  plague,  the  people  with  fear  abandoned  the  sick.  The  excessive 
mortalitv  resulted  from  terror  at  the  mysterious  seizure  and  the  want  of  the 
commonest  aids,  thousands  being  carried  off  by  want  of  care,  as  well  as  by 
dvsentery  and  congestion  of  the  lungs,  which  set  in  as  complications.  The 
effect  of  crowd-poisoning  in  measles  was  well  illustrated  in  the  mortality  of 
measles  among:  the  Confederates  in  the  War  of  the  Rebellion,  where  1900  of 
the  38,000  cases  terminated  fatally.  In  two  of  the  larger  hospitals  the  mor- 
tality (still  according  to  Hirsch)  amounted  to  20  per  cent,,  and  in  some  of  the 
improvised  hospitals  about  Paris  in  the  Franco-Prussian  War  (1871)  it  reached 
40  per  cent.  Mastorman  says  that  at  the  beginning  of  the  Brazilio-Paraguayan 
War  measles  swept  off  nearly  one-fifth  of  the  national  army  in  three  months, 
not  from  the  severity  of  the  disease,  for  he  treated  about  fifty  cases  in  private 
])i-actice  without  losing  one,  but  from  want  of  shelter  and  proper  food. 

Etiology. — Measles  knows  no  consideration  of  geography,  climate,  sex, 
race,  or  caste — resjwcts  nothing  but  sanitation,  which  puts  a  muzzle  on  it  and 
makes  it  mild.  If,  therefore,  the  disease  seemed  to  prevail  more  extensively 
and  severely  among  the  colored  race,  it  was  not  because  of  physiological  pref- 
erence, but  of  unfavorable  hygiene. 

Susceptibility  to  the  disease  is  almost  universal,  so  that  it  has  been  said  that 


ETIOLOGY.  233 

if  measles  had  the  mortality  of  scarlet  fever  the  human  race  would  have  long 
.since  become  extinct.  The  eminent  contagiousness  of  the  disease  is  shown  in 
the  attack  of  whole  communities  previously  entirely  or  for  a  long  time  exempt, 
as  in  the  Faroe  Islands,  where  6000  people  were  seized  at  once,  and  in  the 
cases  of  extensive  prevalence  just  mentioned.  In  1886  the  disease  overran 
nearly  the  whole  of  Russia.  The  universal  susceptii)ility  is  best  observed  in 
the  cases  of  isolated  islands.  Up  to  the  present  time  the  disease  has  visited 
the  Faroe  Islands  four  times  (1781,  1846,  1862,  1875),  and  Iceland  four  times 
(1644,  1694,  1846,  1868).  In  some  of  these  cases  the  intervals  between  epi- 
demics have  been  so  great  as  to  have  furnished  a  large  amount  of  material  for 
attack,  so  that  upon  some  occasions  only  a  few  old  people,  tiicy  who  had  the 
disease  in  infancy,  were  left  to  attend  upon  tiie  sick.  Measles  has  in  these 
cases  suspended  all  business  operations  and  inflicted  upon  a  community  as 
much  distress  as  the  gravest  infections.  Measles,  therefore,  makes  up  for  its 
mildness  by  its  range. 

Universal  susceptibility  implies  exquisite  contagiousness.  The  poison  of 
measles  is  eminentlv  diffusible.  It  must  be  verv  lio-lit.  It  floats  in  the  atmo- 
sphere  about  a  patient  and  does  not  stick  long  to  things. 

The  first  experimental  proof  of  the  contagiousness  of  the  disease  was  fur- 
nished by  Home  of  Edinburgh  in  1758,  at  the  instigation  of  Mnnro.  Home 
soaked  rags  in  blood  from  cuts  made  througii  the  spots  of  measles  and  applied 
them  for  three  days  upon  fresh  cuts  in  the  arms  of  healtiiy  persons,  inducing 
thereby  veritable  but  much  milder  attacks  than  the  prevalent  form.  The  sat- 
urated rags  retained  their  infectiousness  but  ten  days.  There  seems  to  be 
no  doubt  as  to  the  infectiousness  of  the  blood.  Katona  in  1842  failed  to 
inoculate  the  disease  in  but  7  per  cent,  of  1222  cases.  He  used  bhtod  mixed 
with  other  fluids,  sometimes  with  the  fluid  of  vesicles,  sometimes  tears.  A  red 
areola  formed  about  the  point  of  inoculation,  to  be  followed  in  seven  days  by 
fever  and  the  ordinary  prodromata.  The  eruption  appeared  in  nine  or  ten 
<]ays,  and  the  disease  ran  a  regular  but  milder  course.  Joerg  and  Wendt  made 
the  same  experiments,  produced  measles,  but  failed  to  find  any  mitigation  of 
type,  so  tiiat  any  hope  of  protection  by  inoculation  proved  futile.  Mayr 
claimed  to  be  able  to  inoculate  measles  with  the  nasal  nuicus  apj)lied  directly 
to  the  mucous  membrane  of  children  ;  and  Berndt  asserts  that  Monroe  and 
Lock  succeeded  in  producing  the  disease  with  desquamations  of  skin,  with 
tears,  and  with  saliva. 

There  is,  however,  uniformity  of  opinion  only  as  regards  the  blood,  "^riie 
fact  is,  there  is  need  of  more  modern  investigation  with  modern  methods  of 
control.  The  disease  is  certainly  contagious  throughout  its  entire  course,  most 
intensely  so  at  the  period  of  fullest  efflorcsencc — /.  e.  at  its  acme — less  during 
the  stage  of  incubation,  least,  if  at  all,  during  and  after  desquamation. 

Measles  prevails  more  distinctly  in  the  colder  months.  Of  the  epidemics 
tabulated  by  Plirsch,  3390  occurred  in  the  nAAw  mid  l!)l  in  ihc  wanner 
months.  The  frequency  of  epidemics  in  w  Iiii<r  has  usually  been  ascribed  to 
the  closer  contact  of  people  at  this  season.      It  is  cei-tainly  observed  in  cities 


234  MEASLES. 

that  the  disease  assumes  epicleiiiie  proportions  with  opening  of  schools  and 
kindergarten.  These  institutions  especially  seem  to  disseminate  the  disease, 
because  measles  is  a  children's  disease,  and  a  children's  disease  because  it 
attacks  at  the  earliest  exposure.  Escape  in  childhood  by  no  means  secures 
exemption,  as  is  evidenced  by  the  attack  of  people  of  all  ages  in  isolated 
regions.  Kindergarten  are  thus  sometimes  ironically  said  to  be  institutions 
for  the  dissemination  of  infectious  diseases.  Hirsch  is  unwilling  to  admit 
that  the  greater  frequency  of  the  disease  in  winter  is  due  to  closer  contact, 
as  the  same  frequency  is  observed,  he  says,  in  the  tropics,  in  India,  South 
China,  and  Brazil. 

Measles  occurs  at  all  ages,  preferably  from  one  to  five,  the  period  of  earliest 
exposure — rarely  among  sucklings,  the  age  of  least  exposure.  Part  of  the 
exemption  of  very  young  infants  under  six  months  must  be  due  to  compara- 
tive insusceptibility.  Geissler  reports  of  Meerane  in  1861  that  1754 — that  is, 
nearly  60  per  cent. — of  the  children  were  attacked  in  the  following  propor- 
tions regarding  age  :  under  three  months,  12.07  per  cent. ;  three  to  six  months, 
18.05  per  cent. ;  six  months  to  one  year,  35.06  per  cent.  ;  one  to  two  years, 
56.5  per  cent. ;  two  to  three  years,  61.2  per  cent. ;  three  to  four  years,  67.9 
per  cent.;  four  to  five  years,  70.9  per  cent.;  five  to  six  years,  72.5;  six  to 
seven  years,  77;  seven  to  eight  years,  81.3;  and  thereafter  a  progressive 
decline,  based  of  course  upon  smaller  numbers,  as  children  at  more  advanced 
age  had  secured  exemption  by  previous  attack. 

The  susceptibility  to  measles  is  so  great,  however,  that  even  the  youngest 
children  do  not  entirely  escape.  Steiner  reports  cases  in  children  of  foiu^  or 
five  weeks  of  age;  Monti  recorded  two  cases  in  children  under  two  months; 
Lomer  and  Williams  declare  that  the  foetus  may  be  affected ;  Thomas  says 
that  after  considerable  search  he  was  able  to  discover  but  six  authentic  accounts 
of  children  born  with  measles  where  the  diagnosis  could  be  established  by  the 
actual  presence  of  the  eruption  at  the  time  of  birth.  Redness  and  desquama- 
tion alone  cannot  be  accepted  as  evidence  of  the  disease,  as  these  appearances 
are  often  presented  in  perfectly  healthy  children.  It  is  certain  that  pregnancy 
is  no  defence. 

As  a  rule,  but  very  slight  exposure  suffices  fi;r  the  reception  of  the  dis- 
ease. It  is  assumed,  because  the  fact  may  not  be  demonstrated,  that  the  poison 
is  inhaled,  and  that  it  is  received  also  upon  the  exposed  mucosse.  The  fact 
that  affection  of  the  conjunctiva  and  the  nasal  mucosa  assumes  such  })romi- 
nence  in  the  very  early  history  of  the  disease  lends  support  to  this  view. 
The  virus  of  whatever  nature — it  is  almost  safe  to  declare  it  a  micro-organism 
— probably  does  not  require  a  broken  surface  to  secure  absorption,  but  pene- 
trates to  the  superficial  lymj)li-vesscls  in  the  mucous  membrane  upon  which 
it  lodges.  The  length  of  ex.posure  necessary  to  secure  or  escape  infection  will 
necessarily  depend  upon  the  intensity  or  concentration  of  the  cause  in  the 
atmosphere.  Thus,  in  a  close,  hot,  badly-ventilated  room  emanations  accum- 
ulate to  such  degree  as  to  render  the  atmosjihere  highly  infectious,  whereas 
a  larger,  well-ventilated  apartment   may  so  dilute  and  so  diffuse  the  poison 


ETIOLOGY.  235 

as  to  require  a  much  longer  stay  to  secure  infection,  if  the  individuals  exposed 
do  not  escape  it  altogether.  Tiie  better  ventilation,  as  by  open  doors  and  win- 
dows, and  the  presence  of  fewer  people  in  apartments,  have  been  brought  for- 
ward to  account  for  the  comparative  freedom  from  the  disease  in  summer. 

The  poison  of  measles  has,  however,  by  no  means  the  tenacity  of  life 
or  duration  of  existence  of  that  of  scarlet  fever.  Rags  soaked  in  the  blood 
of  measles  may  retain  infection,  as  stated,  for  ten  days,  but  clothing  con- 
taminated under  ordinary  exposure  soon  loses  its  infectiousness.  The  cause 
of  measles  clings,  however,  for  a  time  to  all  objects  upon  which  it  may 
fall.  Cases  are  abundantly  recorded  in  which  the  disease  has  been  conveyed 
by  third  parties  and  things,  the  so-called  fomites.  Thus,  Pamun  records  an 
instructive  case  where  measles  broke  out  in  an  isolated  house  visited  by  no  one 
except  a  physician,  who  had  reached  the  house  two  weeks  before  after  having 
travelled  four  miles  in  an  open  boat  in  stormy  weather.  Thuessink  declares 
that  he  knew  of  a  case  caused  by  a  letter  which  had  been  sent  from  an  infected 
house,  and  a  similar  case  produced  by  an  engraving  sent  by  mail. 

As  a  rule,  measles  attacks  but  once.  One  attack  confers  immunity  for  the 
rest  of  life.  The  older  writers  (Willan,  Rosenstein)  made  this  declaration 
dogmatic,  and  maintained  that  subsequent  attacks  were  mistakes  in  diagnosis. 
Henoch  believes  this  statement  to  be  exaggerated.  It  is  certain  that  authentic 
cases  of  second  and  third  attacks  have  been  recorded.  Spiess  declared  that  in 
the  Frankfort  epidemic  of  1866-67  recurrences  were  unusually  frecpient.  This 
testimony  is,  however,  invalidated  by  the  statement  that  nearly  half  the  cases 
were  recurrences  or  relapses  from  this  or  a  previous  attack,  Most  of  these 
cases  must  have  been  cases  of  rotheln.  We  may  not  deny  the  testimony  of 
such  competent  observers  as  Henoch,  Kassowitz,  Prunach,  and  others,  but 
every  case  of  second  or  repeated  attack  should  be  regarded  with  scepticism 
until  the  evidence  of  the  existence  of  the  disease  is  incontestably  established. 
When  Panum  states  of  the  epidemics  of  the  Faroe  Islands,  which  occurred  at 
such  distinct  intervals,  that  he  never  saw  a  second  attack  ;  when  we  recall  the 
fact  also  that  in  the  widespread  epidemic  of  the  AVar  of  the  Rebellion  in  this 
country  the  disease  was  almost  exclusively  confined  to  reginients  from  the 
country  towns,  sparing  the  regiments  from  the  cities,  whose  inhabitants  almost 
never  escape  attack  in  childhood, — we  must  look  with  credulity  upon  state- 
ments of  repeated  occurrences.  Where  the  case  in  question  is  undoubtedly 
measles,  the  character  of  the  first  or  ])revi()us  attack  should   be  cstablislnd 

beyond  doubt. 

Measles  may  certainly  coexist  with  other  infections — with  scarlet  fever, 
with  rotheln,  with  typhoid  fever,  and  most  esi)ecially  and  licqiiently  with 
pertussis.  An  unmistakable  coincidence!  is  mentioned  l>y  Pamim,  who  vacci- 
nated a  child  in  the  incubative  stage  of  the  disease,  both  vaccinia  nnd  measles 
running  typical  courses.  With  the  excepti(Mi  ol"  pertussis,  the  existence  of  :ui 
acute  disease  as  a  ride  postpones  an  attack  of  measles  until  alter  its  subsidence. 
Coincidence  is  therefore  an  exception  to  the  rule.  An  inl<Testing  contribution, 
as   illustrating  the  did'erenee   in  susceptibility  l(.  measles  and  searhitiiia.  w:is 


236  MEASLES. 

made  by  Faber  and  Heyfelder,  who  showed  that  during  the  prevalence  of 
both  diseases  the  convalescents  from  scarlet  fever  were  frequently  attacked 
by  measles,  while  convalescents  from  measles  were  rarely  attacked  by  scarlet 
fever.  Thomas  and  Gruel  made  the  same  observations  in  regard  to  measles 
and  rotheln. 

The  contagiousness  of  measles  is  established  bevond  a  doubt,  if  onlv  bv  the 
rapid  dissemination  of  the  disease,  but  experimental  evidence  has  been  estab- 
lished absolutely  thus  far  only  with  the  blood  and  nasal  mucus.  The  disease 
is  disseminated  not  from  the  blood,  but  from  some  of  the  emanations  of  the 
body.  The  infectious  character  of  all  the  secretions  has  been  so  often  declared 
and  denied  that  the  source  of  real  infection  still  remains  in  doubt.  It  must, 
however,  be  something  in  the  nature  of  a  living  organism,  if  only  from  the 
fact  of  the  rapid  multiplication  of  the  disease.  Hallier  believed  that  he  had 
discovered  it  in  certain  micrococci ;  Salisbury  in  1862  claimed  to  have  found  it 
in,  and  propagated  it  from,  a  straw  fungus.  Wood  and  Pepper  were  not  able 
to  verify  these  observations.  Coze,  Fels,  and  Keating  isolated  micrococci  from 
the  blood;  Le  Bel,  bacilli  from  the  urine;  Eklund  in  1882,  chain  micrococci 
(torulse  morbillorum)  from  the  sputa ;  and  Braidwood  and  Vacher  collected 
certain  spherical  bodies  upon  glycerin  slides  exposed  to  the  breath  of  patients 
affected  with  measles ;  they  found  the  same  bodies  in  the  lungs,  and  hence  as- 
sumed that  the  lungs  evolved  the  disease.  None  of  these  studies  were  made 
with  modern  methods.  None  of  them  disclose  any  other  pathogenetic  relation 
to  the  disease  than  presence.  Lambroso  failed  to  discover  any  micro-organisms 
in  the  blood,  though  he  found  a  small  round  coccus  in  the  eruption  in  the  first 
three  or  four  days.  Leyden  also  saw  the  same  or  a  similar  micro-organism, 
but  with  no  other  definite  relation  to  the  disease. 

A  further  contribution  to  the  bacteriology  of  measles  was  made  by  Cornil 
and  Babes  in  their  studies  of  the  pneumonic  complication.  These  observers 
found  in  the  lungs  of  children  affected  with  measles  large  masses  of  diplococci, 
distinguished  by  their  biscuit  shape  and  arrangement  in  pairs.  These  diplo- 
cocci accumulate  in  the  infiltration  of  the  interstitial  tissue,  and  are  found 
abundantly  also  in  the  lymph-  and  blood-vessels,  less  abundantly  in  the  alve- 
oli themselves.  Babes  says  that  he  was  able  to  isolate  from  the  blood  of  the 
papules  of  measles,  as  well  as  from  the  lymph-glands  and  pneumonic  centres, 
a  streptococcus  which  showed  in  its  shape  and  culture  great  similarity  to  the 
streptococcus  pyogenes.  These  micro-organisms  are,  however,  not  believed  to 
stand  in  any  genetic  relation  with  measles  itself.  They  cannot  be  considered 
as  the  specific  causes  of  the  disease,  but  are  probably  the  well-known  pneu- 
monia diplococci  of  FrJinkel  and  Weichselbaum  and  the  common  streptococcus 
of  pus.  They  are  the  products  of  mixed  or  secondary  infection.  They  may 
account  for  complications,  but  not  for  the  disease  itself. 

The  real  cause  of  measles  remains  as  yet  undiscovered.  A  difficulty  in  the 
way  of  observation  lies  in  the  fact  that  the  disease  is  not  known  to  occur  in 
the  lower  animals.  It  must  soon 'be  discovered  at  least  in  the  blood,  where 
evidence  of  the  existence  of  the  contagium  is  proven  without  doubt.     In  these 


COCRS?:    OF    TITK    DISEASE.  237 

davs  of  rapid  discovery  in  tiic  field  of  tiie  infections  the  interval  between  ])ress 
and  publication  may  cover  its  period  of  disclosure.     In  I'act,  in  this  very  inter- 
val, on  this  occasion,  Canon  and  Pfeiifer  (1892)  declare  that  they  have  discov- 
ered the  specific  bacillus  of  measles  in  the  blood  and  in  mucus  from  the  nose 
and  conjunctiva.     They  used  the  method  successfully  employed  in  the  case  of 
influenza — to  wit,  concentrated  aqueous  solution   of  methylene  blue  40.0  ;  5 
per  cent,  solution  of  eosine  (in  70  per  cent,  alcohol)  20.0;  distilled  water  40.0. 
The  preparations  are  immensed  in  absolute  alcohol  five  to  ten  minutes,  then 
.stained  in  the  incubator  at  37°  C.  from  six  to  twenty  hours.    The  bacilli  thus 
disclosed  vary  in  size,  but  were  uniformly  present  in  every  one  of  fourteen  cases 
examined.     The  cause  of  the  disease  j^robably  escapes  from  the  body  through 
the  nasal  mucus,  which,  dried  and  infinitely  subdivided,  floats  in  and  con- 
taminates the  atmosphere  about — that  is,  in  the  close  vicinity  of — the  patient. 
Mayr  certainly  succeeded  in  propagating  the  disease   with  mucus  from  the 
nose.     Mucus  collected   from   a   patient  in    the  height  of  the  eruption   was 
conveved  in  a  glass  tube  and  inserted  upon   the  mucous   membrane  of  the 
nose  of  two  healthy  children   living  at  some  distance  fiom  each  other,  some 
time  after  an  epidemic  of  measles.     In  one  of  these  children  sneezing  set  in 
in  eio-ht,  in  the  other  in  nine,  davs.     Fever  followed  two  davs  later,  the  cha- 
racteristic  rash  appeared  on  the  thirteenth  day,  and  the  disease  ran  its  regular 
course. 

Course  of  the  Disease. — The  period  of  incubation,  the  lapse  of  time 
between  exposure  and  the  appearance  of  the  first  symptoms,  as  determined  by 
inoculation  experiments  and  observations  by  conveyance  of  single  cases  to  iso- 
lated places,  is  quite  definitely  established  at  ten  days — that  is,  fourteen  days 
before  eruption.  The  most  indisputable  observations  were  furnished  by  Panuni 
in  the  Faroe  Islands,  so  frequently  referred  to.  It  w^as  easy  in  these  cases  to 
trace  up  the  source  of  infection,  which  corresponded  to  the  landing  of  a  case 
from  a  ship.  In  all  these  cases  thirteen  or  fourteen  days  elapsed  from  the 
day  of  exposure  to  the  beginning  of  the  eruption.  An  almost  too  perfect  case 
was  reported  by  I^Iyrtle.  Measles  broke  out  in  a  young  ladies'  boarding-school 
with  thirty-five  resident  scholars.  The  girl  affected  was  isolated  in  an  adjoin- 
ing house,  and  in  the  course  of  twelve  days  was  sent  home  and  the  house  and 
everything  in  it  thoroughly  disinfected.  "  Exactly  fourteen  days  after  this  girl 
showed  the  disease  a  second  case  occurred,  fourteen  days  after  that  a  third,  four- 
teen days  after  that  a  fourth,  and  fourteen  days  after  that  a  fifth.  Nos.  1,  2,  3, 
and  5  belonged  to  different  classes  and  slcjit  in  diflercnt  rooms.  Nos.  1  and  4 
were  sisters  and  slept  together,  and  No.  4  showed  the  disease  eight  weeks  after 
her  sister."     We  may  coincide  with  the  author  that  "  comment  (»n  these  clinical 

records  is  needless." 

The  universal  existence  of  the  disease  and  the  infniite  sources  of  infection 
render  accuracy  of  observation  elsewhere  almost  impossible,  hcnee  the  varia- 
tion in  time  from  one  week  to  three  given  to  this  perio.i  l)y  various  aulhors. 

The  period  (.f  incubatit.n  is  in  the  va>t  majority  of  cases  wholly  fnrof 
.symptoms.     Very  exceptional  cases  show  malaise  or  ephemeral   fever,  whicli 


238 


MEASLES. 


may,  but  often  does  not,  arise  from  the  poison  of  the  disease.  The  stage  of 
invasion  may  be  marked  by  a  distinct  chill  or  more  commonly  by  a  series  of 
shiverings,  to  be  attended  or  followed  by  a  rise  in  temperature  to  100°-104° 
F.,  with  gastric  irritation  and  nervous  symptoms  in  correspondence  with  the 
temperature.  The  fever  is  in  many  cases  so  slight  as  to  be  overlooked,  when 
the  disease  may  announce  itself  with  more  distinctive  signs.  After  the  first  re- 
mission the  temperature  again  rises  with  the  appearance  of  the  eruption  (Fig.  14), 
to  reach  its  acme  at  the  period  of  full  efflorescence,  and  to  decline  as  it  fades 


Fio. 

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Measles — Defervescence  by  Crisis. 

away.  In  an  average  case  the  fever  falls  by  crisis — that  is,  within  thirty-six 
hours  after  the  first  decisive  fall  (Fig.  15).  During  the  stage  of  invasion  charac- 
teristic catarrhal  symptoms  show  themselves  in  the  mucous  membrane  of  the 
nose,  eyes,  throat,  and  bronchial  tubes.  These  symptoms  are  summed  up  under 
the  term  "coryza."  The  eyes  grow  intolerant  to  light,  the  conjunctiva  is 
hypersemic,  the  nose  "runs,"  the  eyes,  nose,  and  throat  itch  and  burn — 
sensations  but  partially  relieved  by  more  or  less  sneezing  and  cough.  The 
uvula  and  soft  palate  now  show  dark-red  spots,  and  later  diffuse  redness,  the 
so-called  enanthem,  the  first  appearance  of  the  eruption.  Bronchitis,  the 
result  of  direct  invasion  of  the  bronchial  tubes,  belongs  to  measles  as  def- 
initely as  the  eruption. 

In  an  average  case  the  first  evidence  of  affection  may  be  a  disturbance  of 
disposition.  The  child,  usually  cheerful  and  animated,  becomes  listless,  indif- 
ferent, fretfid,  feverish  ;  or  attention  may  be  first  attracted  to  the  (ihild  by  a 
sudden  fit  of  sneezing  not  to  be  accounted  for  by  any  perceptible  exposure. 
Irritation  about  the  nose  is  further  manifested  by  itching  and  burning,  which 
the  patient  may  attempt  to  relieve  by  manipulation.     It  is  observed  also  that 


COURSE    OF    THE    DISEASE.  239 

the  eyes  arc  reddened  and  tears  flow  over  upon  the  face.  The  dryness  of  the 
nose  felt  at  first  is  soon  relieved  by  a  discharge  of  watery  fluid,  which  may 
accumulate  to  trickle  down  upon  the  upper  lip.  There  often  is  complaint  of 
dryness  and  soreness  in  the  throat,  inspection  of  which  frequently  at  once  dis- 
closes dark-red  spots  about  the  uvula  and  soft  palate,  some  of  which  may 
coalesce  to  present  more  or  less  extensive  erythematous  discolorations  of  the 
surface.  There  is  the  same  evidence  of  irritation  in  the  bronchial  tubes. 
The  cough  is  more  or  less  frequent  and  distressing,  and  auscidtation  may 
reveal  an  abundance  of  drv  rales  thus  early  in  the  disease.  So  Ions:  as  the 
bronchitis  is  confined  to  the  larger  tubes  all  physical  signs  may  be  absent.  As 
a  rule,  these  catarrhal  signs  are  obtrusive.  They  mark  the  onset  of  the  disease 
unmistakably  as  regards  the  diiferential  diagnosis  between  this  affection  and 
scarlet  fever  or  small-pox. 

These  signs  may,  however,  be  very  slight  (morbilli  sine  catarrho),  wiien  the 
nature  of  the  disturbance  may  be  revealed  only  by  careful  study  of  the  tem- 
perature. It  is  seen  that  the  temperature  rises  to  100°-102°  F.  in  the  evening, 
and  that  it  does  not  entirely  subside  on  the  next  day.  It  is,  however,  as  a 
rule,  very  irregular  during  the  period  of  invasion.  It  may  fall  to  the  nor- 
mal on  the  second  day,  to  rise  slightly  on  the  third,  and  maintain  itself  at 
this  elevation  or  fall  again  on  the  fourth  or  even  the  fifth  dav,  to  meet  its 
characteristic  elevation  with  the  appearance  of- the  eruption.  The  irregularity 
of  the  temperature  during  the  period  of  prodromata  speaks  thus  more  definitely 
for  measles,  as  the  temjierature  of  scarlet  fever,  as  a  rule,  is  a  continuous  eleva- 
tion up  to  the  period  of  the  eruption.  An  association  of  catarrhal  symptoms, 
more  especially  the  presence  of  an  enanthem,  with  a  light  rise  or  irregular 
course  of  the  temperature  during  the  first  few  days,  ainiounces  the  advent  of 
measles.  The  stage  of  invasion  lasts,  as  a  rule,  three  full  days,  exceptionally 
four,  still  more  exceptionally  five  or  six. 

The  four  temperature-charts  here  reproduced  (see  Fig.  IG),  adapted  from 
Henoch  (translated  into  Fahrenheit),  illustrate  varieties  of  invasion  in  per- 
fectly normal  measles. 

The  affection  of  the  upper  respiratory  tract  is  a  feature  of  measles  so  con- 
.stant  as  to  have  been  always  recognized  from  the  beginning  of  time.  This 
feature  assumes  especial  value  in  the  colored  race,  where  the  discolorations  of 
the  eruption  proper  may  be  but  indistinctly  or  not  at  all  observed.  It  is 
rather  the  rule  tlian  the  exception  that  even  as  early  as  the  end  of  the  first 
day,  certainly  by  the  end  of  the  second,  the  hypcMwmia  which  marks  the 
catarrhal  process  in  the  throat,  more  especially  the  palate,  is  so  intense  as  to 
produce  the  appearance  of  an  eruption.  Dark-red  spots,  varying  in  size  from 
that  of  a  pin's  head  to  that  of  a  ])ea,  are  phiinly  visibh-  upon  the  palalc  and 
uvula,  presenting  at  times  a  distinctly  spotted  appearance.  The  nuicous  mem- 
brane of  the  lii)s,  of  the  cheeks  less  frequently,  occasionally  (he  conjunctiva 
itself,  may  show  the  same  spots,  the  so-called  enanthem,  which  disapjicars  as  a 
rule  entirely  before  the  true  eruption  shows  itsclldn  the  skin.  The  enanthem 
extends  also  to  the  deeper  mucosae.     Steiner  saw   it   in  lit;'  in  the  hrynx  and 


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Toini)urat\irc-(harts  of  Four  Typical  Cases  of  Measles,  from  Invasion  to  Appearance  ot  Eruption. 
240 


COURSE    OF    THE   DISEASE.  241 

in  autopsies  deep  in  the  bronehial  tubes.  Wilson  anil  Kay  observed  it  in  the 
traehea,  and  Gerhardt  on  the  posterior  wall  of  the  trachea.  Heyfelder  dec-lares 
that  he  found  an  eruption  like  measles  on  the  niueous  membrane  of  the  duo- 
denum ;  Weber  and  Lieutaud  as  far  down  as  the  ileum.  Fuehs  says  that  the 
genital  mucosa  may  be  covered  with  the  same  numerous  red  spots — a  statement 
whicii  both  Henoch  and  Sehomel  sujiport. 

The  eruption  proper  is  seen  first,  as  a  rule,  on  the  mornino;  of  the  fourth 
day,  exceptionally  as  early  as  the  end  of  the  third  or  as  late  as  the  fifth  day. 
The  eruption  proper  shows  itself  in  "spots"  (measles),  usually  somewhat  ele- 
vated, dark  red,  "raspberry"  red,  or  tinged  with  blue,  first  upon  the  forehead 
and  sides  of  the  face.  It  distinguishes  itself,  especially  upon  the  face,  by 
coalescence  and  aggregation  into  irregular  or  crescentic  patches,  with  inter- 
vening islets  of  unaffected  tissue.  During  fidl  efflorescence  the  face  seems 
puffed  and  swollen.  The  eruption  gradually  spreads  downward  over  tlie 
neck,  chest,  trunk,  and  extremities,  to  cover  the  whole  surface  by  the  eighth 
day.  More  or  less  confluent  on  the  face  and  neck,  it  gradually  grows  more 
and  more  discrete  over  the  trunk,  legs,  and  feet.  Reaching  the  lower  extremi- 
ties, it  begins  to  fade  from  the  face.  Desquamation,  whicli  is  absent  in  light 
cases,  is  furfuraceous  as  a  rule. 

The  first  appearance  of  the  eruption  is  always,  except  in  the  most  debili- 
tated subjects,  attended  with  a  significant  elevation  of  temperature.  The  record 
rises  to  102°,  104°,  or  105°  F.,  along  with  the  general  signs  of  distress,  per- 
haj)s  ev'en  light  delirium,  heat  of  the  skin,  dryness,  arrest  of  the  secretions. 
The  temperature  rises,  the  discomfort  increases,  perhaps  as  yet  the  diagnosis 
may  fail  to  have  been  established,  when  all  at  once  at  the  proper  time  the 
eruption  displays  itself  upon  the  face,  often  to  the  relief  of  the  practitioner 
as  well  as  the  parents,  if  not  of  the  [)atient  himself.  It  shows  itself  first,  as  a 
rule,  about  the  temples,  near  the  ears,  or  on  tiie  chin  in  the  form  of  minute, 
flat  papula;  of  the  size  of  a  pin's  head  or  a  pea,  usually  brighter  in  color  on 
first  appearance.  It  difl'uses  itself  rapidly  over  the  whole  face,  neck,  and 
chest,  and  may  indeed  extend  over  the  entire  body  to  the  toes,  within  the 
space  of  twenty-four  hours,  being  always,  however,  more  confluent  in  the 
upper  half  of  the  body.  When  it  aj)pcars  rapidly  or  spreails  raj^dly  over  the 
face,  it  usually  spreads  rapidly  also  over  the  body  :  showing  itself  but  scantily 
or  sparsely  about  the  face,  it  may  take  several  days  to  extend  over  the  entire 
body.  This  slower  progress  is  observed  still  more  markedly  in  cases  of 
anomalous  a|)pcarance,  where,  for  instance,  the  eruption  shows  itself  first  over 
the  chest  or  back.  It  may  spread  irregularly,  fitfully,  or  freakishly  over  the 
body,  and  is  then  wont  to  be  attended  with  grave  complications.  The  ))a|)ules 
seem  to  be  at  first  arran<''ed  about  the  hair-fbllides  or  sweat-u-lands,  and  auirrc- 
gate  themselves  in  patches  which  assiuuc  something  of"  half-moon  or  crescentic 
outline.  Very  often  the  eruption  above  the  surface  iss(»  slight  that  the  pa|)ular 
character  can  be  recognized,  as  Sydenham  said  long  ago,  only  by  the  touch. 
The  eruption  reaches  its  h(;iglit  in  lioni  thirty-six  to  forty-eight  hours:  the 
period  of  eflloroscencc  and  the  height  of  the  fever  correspond  with  its  duration. 

Vol..  I.  — 16 


242 


MEASLES. 


As  soon  as  the  fever  has  reached  its  height  it  begins  to  fall,  and  falls  rapidly, 
to  terminate,  as  stated,  by  crisis  within  thirty-six  or  forty-eight  hours.  This 
fall  of  the  temperature,  with  the  appearance  of  the  eruption,  is  so  characteristic 
as  to  often  enable  the  observer  to  differentiate  measles  in  cases  of  doubtful  erup- 
tion from  simulating  maladies.  (See  Fig.  17.)    There  is  the  appearance  that  the 


Fig.  17. 


Scxwlalina .  J^ecislcs. 

Temperature-chart  of  Case  of  Bleasles  after  Scarlatina  (Moore). 


body  struggled  with  the  disease,  and  finally  succeeded,  as  the  old  writers  be- 
lieved, in  throwing  it  off  in  an  eruption.  With  the  discharge  by  eruption  the 
fever  falls.  The  disease,  however,  is  not  really  in  the  eruption.  The  eruption 
is  probably  only  a  toxic  reflex,  like  urticaria,  herpes,  etc.  The  fact  is  that  the 
fall  of  temperature  is  observed,  as  a  rule,  before  the  eruption  has  reached  its 
full  height.  When  it  is  on  the  eve  of  efflorescence,  as  if  a  poison  had  been 
voided  from  the  blood,  the  temperature  falls  rapidly.  So  the  crisis  occurs 
often  within  forty-eight  hours  after  the  appearance  of  the  eruption,  and  hence 
measles,  barring  complications,  is  a  mild  disease.  Measles  is  therefore  a  little 
(short)  disease.  At  the  end  of  forty-eight  hours  after  the  appearance  of  the 
eruption  there  is  in  most  cases  no  fever  at  all,  and  in  many  cases  actually  a 
subnormal  temperature,  at  least  in  the  morning.  So  well  established  is  this 
fact  in  measles  that  the  persistence  of  temjierature  or  the  existence  of  an  eleva- 
tion of  even  one  or  two  degrees  on  the  third  or  fourth  day  after  the  appear- 
ance of  the  eruption  betokens  a  complication  which  will  probably  announce 
itself  with  its  distinctive  signs  in  the  course  of  a  day  or  two.  Where  records 
of  temperature  are  faithfully  kept  complications  are  thus  often  announced  before 
they  assume  distinct  proportions. 


ABNORMITIES,    COMPLICATIONS,    AND    SEQUELAE.        243 

The  clinical  history  of  an  average  uneomjiliontod  case  of  measles  implies 
thus  ten  to  fourteen  days'  inculcation — three  days'  invasion,  three  days'  prog- 
ress, and  three  days'  decline.  The  eruption  really  remains  at  its  height  but 
twenty-four  hours.  It  begins  to  fade  as  soon  as  it  has  reached  its  maximum 
development.  It  loses  its  efflorescence  by  the  end  of  the  second  day,  to  show 
upon  the  face  only  i)ale  or  lightly  tinted  s])ots,  while  it  extends  itself  over  the 
body  in  full  flush  and  hue.  Light-yellow  or  yellowish-gray  sjwts  are  left 
behind  for  a  few  days,  which  give  to  the  skin  something  of  a  marbled  appear- 
ance. A  mild  case  may  desquamate  but  little.  In  most  cases  the  desquamation 
occurs  in  fine  brannv  dust.  Scales  of  skin  are  never  shed  after  measles,  and 
strips  or  lamellre,  such  as  are  removed  from  the  palms  of  the  hands  and  soles 
of  the  feet  or  from  the  fingers  and  toes  in  scarlatina,  are  never  seen. 

Individual  cases  show  every  variation  of  intensity  and  degree  of  symptom. 
It  has  been  remarked  that  measles  is  a  disease  which  shows  constant  phenom- 
ena. Measles  has  always  been  measles  from  the  beginning  of  time.  There  is, 
however,  great  range  of  intensity  in  the  expression  of  individual  symj)t()ms, 
however  unifi)rm  they  may  be  in  their  occurrence.  Strong,  healtiiy  children 
are  at  times  affected  with  a  form  so  mild  as  to  be  able  to  go  about  continuously 
and  to  be  scarcely  disturbed  in  disposition.  As  a  rule,  however,  there  is  such 
aflPection  of  the  conjunctiva  as  to  lead  to  photophobia  and  epiphora.  On  the 
other  hand,  burning  sensations  in  the  eyes  and  ocular  symptoms  may  assume 
such  prominence  as  to  call  for  special  treatment.  There  are  always,  as  stated, 
sneezing,  dryness,  and  irritation  of  the  nose.  Symptoms  on  the  part  of  the 
nose,  again,  may  assume  such  prominence  as  to  lead  to  hemorrhage,  whicii 
may  require  special  procedures  for  its  relief  There  is  nearly  always,  in  even 
the  milder  cases,  anorexia,  a  more  or  less  iieavily-'coated  tongue,  some  angina, 
some  pain  in  deglutition.  In  individual  cases  the  inflammation  of  the  mucous 
membrane  of  the  mouth  and  throat  assumes  distinct  proj)ortions.  Stomatitis 
may  develop  :  in  cases  with  bad  surroundings  even  gangrene  of  the  cheeks 
and  noma.  Measles  is  not  infrequently  announced  by  vomiting,  and  in  indi- 
vidual cases  the  eruption  extends  to  lower  portions  of  the  gastro-intcstinal 
tract,  and  amiounces  itself  in  a  severe,  profuse,  or  sometimes  bloody  dian-h(ea. 
Witli  the  height  of  the  fever  there  is,  as  a  rule,  such  nervous  disturbance  as  to 
lead  for  a  few  days,  or  rather  nights,  to  light  delirium.  Little  children  easily 
wander  in  their  minds.  Intoxication,  which  is  rarely  associated  with  light 
fever,  102°  or  103°  F.,  may  suffice  to  disturb  the  iutcllecrt  of  a  cliild.  Sen- 
sitive and  delicate  children  may  show  the  gravity  of  the  shock  of  onset  in 
convulsions.  With  the  increase  in  the  fever  there  is  also  corresponding 
increase  in  the  frequency  of  the  pulse  (130  to  1 40)  an<l  respiration  (30  to  40). 
So  long  as  this  increase  corresponds  with  the  elevation  of  tem|)erature,  it 
excites  no  apprehension,  provided  this  elevation  of  temperature  occm*  at  the 
proper  time  in  the  history  of  the  disease — to  wit,  at  the  period  of  eruj)tion. 
Occurring  with  fever  or  without  it  at  a  later  period,  it  may  mean  the  super- 
vention of  very  grave  complication,  espeeially  on  the  |)art  of  the  huigs. 

Abnormities,  Complications,  and  Sequelae. — These  are  of  frequent  occur- 


244  MEASLES. 

rence.  Eitlier  the  eruption  or  tlie  catarrhal  symptoms  may  be  absent — morhiUi 
sine  catarrho,  sine  eruptione— though  some  eruption  may  be  seen  or  fomid  some- 
where under  close  enough  scrutiny.  Blood-poisoning  in  the  stage  of  invasion 
may  be  so  intense  as  to  take  life  at  the  start — rubeola  siderans.  Haemorrhage 
may  show  itself  in  two  forms.  In  the  more  frequent  but  less  grave  form  a 
few  or  manv  of  the  spots  become  petechial.  In  the  true  hsemorrhagic  or 
black  measles — rubeola  nigra — observed  only  in  cachectic  cases  and  degraded 
surroundings,  free  haemorrhage  occurs ;  that  is,  blood  flows  from  the  nose, 
mouth,  kidneys,  vagina,  or  intestines,  and  vibices  and  ecchymoses  appear 
upon  the   surface. 

Xervous  symptoms  may  assume  prominence  :  headache  is  common  and  at 
times  severe.  Invasion,  especially  in  young  children,  may  be  marked  or 
marred  bv  delirium,  coma,  or  convulsions.  True  meningitis  is  rare.  Transi- 
tory albuminuria  is  common,  but  nephritis  is  very  rare.  A  very  sharp  attack 
is  ushered  in  by  anorexia,  nausea,  vomiting — symptoms  which  may  extend 
over  the  period  of  invasion.  Parotitis  is  very  rare,  but  laryngismus,  due  at 
times  to  laryngeal  enanthem,  is  not  at  all  infrequent.  The  picture  of  laryn- 
geal stenosis,  sometimes  as  the  result  of  a  true  crouj)  (diphtheria),  more  fre- 
quently of  a  false  croup  (laryngismus  stridulus),  sometimes  as  evoked  by  a  spot 
of  hypersemia  on  an  exquisitely  sensitive  surface  which  may  be  seen  and 
treated  under  the  laryngoscope,  presents  itself  occasionally  in  the  course  of  the 
disease.  Noma,  a  gangrenous  affection  of  the  mouth  or  vulva,  is  an  ugly  com- 
plication in  cachectic  cases  or  under  exceptionably  degraded  hygienic  surround- 
ings. It  is,  fortunately,  a  rare  complication,  but  measles  (Woronichin)  is  its 
most  frequent  cause.  Catarrhal  pneumonia  is  the  complication  most  frequent 
and  most  feared.  It  is  recognized  by  rise  of  temperature,  frequency  of  breath- 
ing, increase  of  cough,  dyspnoea,  with  the  physical  signs  of  this  disease.  Latent 
tuberculosis  is  brousrht  to  the  surface  by  an  attack  of  measles  as  a  rule.  Hv- 
persemia  of  the  bronchial  tubes  and  glands  excites  quiescent  bacilli  to  quick 
and  active  growth  or  renders  fruitful  a  soil  previously  sterile  to  this  disease. 
The  eruption  of  measles  may  prematurely  disappear — "  strike  in,"  at  any  time, 
not  as  the  cause,  but  the  effect  of  complications.  This  disappearance  of  the 
eruption  with  the  development  of  complication  is,  however,  the  exception,  and 
not,  as  commonly  believed,  the  rule.  The  eruption  runs  its  course,  as  a  rule, 
in  spite  of  the  complication.  Complications  are  due  to  the  nature  of  the 
poison,  to  the  constitnti(m  of  the  individual,  not,  as  commonly  believed,  to 
"catching  cold,"  the  fear  of  which  interferes  with  one  of  the  chief  means  of 
successful  treatment — free  ventilation  of  the  sick-room. 

It  has  been  repeatedly  remarked  that  measles  shows  a  remarkable  uni- 
formity in  symptomatology,  and  has  been  recognized  with  the  same  charac- 
teristics from  the  beginning  of  time.  Measles  is  the  disease  selected  to  illus- 
trate uniformity  of  type  as  dependent  necessarily  upon  uniformity  of  cause; 
yet  individual  cases  do  show  anomalies  regarding  the  catarrhal  symptoms, 
the  eruption,  the   fever,  complications,  etc. 

In  the  first  place,  the  duration  of  incubation  may  vary  somewhat.     Reil 


ABXORMITIES,    COMPLICATIOXS,    AND   SEQUEL. Tl.        245 

claims  to  have  known  of  cases  in  which  the  incubation  lasted  several  weeks. 
The  eruption  varies  in  every  degree  of  intensity.  It  has  been  already 
noticed  that  it  may  appear  as  early  as  the  third  day  or  as  late  even  as  the 
sixth  day,  and  in  its  appearance  it  may  show  itself  almost  simultaneously 
upon  the  face  and  truidc,  or  spread  with  such  rapidity  that  the  interval 
escapes  observation.  In  certain  otiier  exceptional  cases  it  may  ai)pear  first  on 
•  the  chest  or  back.  It  is  seen  in  all  cases  to  show  itself  in  greater  abundance 
and  profusion,  often  also  with  more  marked  coloration,  on  parts  of  the  body 
subjected  to  heat  or  enveloped  in  embrocations.  Surfaces  of  the  body  under 
mustard  plasters  or  poultices  show  the  eruption  intensely  aggravated  in  degree 
and  heightened  in  color.  Petechiae  or  more  extensive  luemorrhagic  eru{)tion 
may  occur  at  any  period  of  the  disease.  Minute  haemorrhages  take  place  not 
infrequently  in  the  bluish-red  traces  of  the  former  exanthem,  and  may  in  no 
way  interfere  with  the  further  mild  course  of  the  disease,  and  have  no  more 
significance  of  danger  than  the  minute  blood-spots  seen  at  times  in  the  palate 
and  pharynx.  These  exudations  have  nothing  to  do  with  the  haemorrhages 
which  constitute  the  malignant  form  known  as  black  measles.  They  disap- 
pear to  leave  no  trace.  Where  the  eruption  is  very  profuse  it  causes  a  uni- 
versal puffiness  of  the  face.  It  may  even  close  the  eyes  or  block  the  nares, 
and  at  times  swell  the  tissues  of  and  about  the  ear,  presenting  some  resemblance 
to  the  distension  and  deformity  of  erysipelas.  The  skin  always  lacks,  how- 
ever, the  glazed  and  shining  appearance  of  this  disease.  There  may  be  usu- 
ally observed  in  cases  of  profuse  eruption  vesicles  scattered  about  the  surface, 
which  assume  at  times  such  prominence  and  profusion  as  to  constitute  a  form 
called  by  the  old  writers  the  morhilli  vesicuhsce.  In  still  rarer  cases  the  ves- 
icles assume  sufficient  magnitude  to  constitute  blebs  or  bullae,  an  affection  of 
the  skin  which  looks  like  and  is  commonly  called  pemphigus,  the  so-called 
viorbilll  buUosce  of  the  older  writers.  Occasionally,  but  more  rarely,  bulhe 
appear  before  the  eruption.  They  may  continue  throughout  its  course  and 
])rotract  the  duration  of  the  disease.  They  have  a  tendency  in  all  cases  to 
aggravate  the  disease,  in  that  they  impart  the  danger  which  is  associated  with 
burns  of  the  skin,  more  especially  ulceration  of  the  intestine  from  thrombus. 
The  contracted  vessels  are  literally  plugged  with  glutinous  blood-corjiuscles 
(Salvioli).  Large  vesicles,  whose  contents  may  bo  more  or  less  tinged  with 
blood,  are  evidence  of  erosive  process,  of  destructive  gangrenous  ulceration, 
and  are  often  associated  with  dangerous  symptoms  of  collajise.  Henoch  warns 
acrainst  the  confusion  of  these  and  similar  cases  with  a  coincidence  of  measles 
and  chicken-pox.  Certain  cases  of  varicella  show  confluent  vesicles  which 
may  j)resent  the  appearance  of  ])emphigus.  Baginsky  saw  a  fatal  case  com- 
plicated  with   hremorrhagic  measles. 

Of  all  the  affections  or  complications  which  pertain  to  mcasl(>s,  none 
assumes  such  prominence  as  disease  of  the  resi)iratory  tract.  The  |)oison — 
micro-organism — falls  upon  the  upper  respiratory  passages  and  is  inhaled 
into  the  bronc-hial  tui)cs,  to  lodge  in  its  course  upon  the  larynx  and  trachea. 
Affections  of  the  larvnx  and  trachea,  as  stated  already,  sometimes  assume 


246  MEASLES. 

prominence.  Even  during  the  period  of  invasion  the  cough  may  assume  a 
ringing  character.  The  epiglottis  and  the  surface  of  the  glottis  may  show 
deposits  of  enanthem.  Hoarseness,  pain,  and  dysphagia  occur  in  certain 
cases.  Cough  is  sometimes  so  continuous  as  to  harass  the  patient  during  the 
day  and  exhaust  the  strength  from  want  of  sleep  at  night.  It  has  at  times 
an  exquisitely  croupous  clang,  wholly  of  nervous  or  muscular  origin,  and 
totally  independent  of  the  slightest  deposit  in  the  way  of  false  membrane. 
These  symptoms  usually  disappear  with  the  outbreak  of  the  exanthem  :  tlie 
cough  ceases  and  the  voice  clears  up.  In  exceptional  cases,  however,  the 
catarrh  of  the  larynx  assumes  a  more  formidable  character.  Exudation  takes 
place  ;  the  epithelial  cells  undergo  transformation  ;  genuine  false  membrane — 
that  is,  croup — develops  in  the  throat,  fortunately  however,  only  as  a  great  excep- 
tion. It  must  be  remembered  also  that  diphtheria  itself  may  coincide  with  or 
follow  measles.  In  fact,  measles  rather  predisposes  to,  or  prepares  the  soil  for, 
the  development  of  diphtheria.  In  all  cases  of  laryngeal  complications  the 
condition  of  the  larynx  should  be  definitely  ascertained,  when  possible,  by  the 
use  of  the  laryngoscope. 

Bronchitis  belongs  to  measles  as  an  integral  factor  in  the  history  of  the 
disease.  So  long  as  it  remains  confined  to  the  largest  and  medium-sized  tubes 
it  is  unattended  with  special  danger.  There  is,  however,  the  constant  tendency 
to  the  extension  of  the  disease,  and  capillary  bronchitis  and  catarrhal  pneu- 
monia are  the  most  frequent  and  the  most  grave  com])lications.  The  mortality 
of  measles  is  really  due  to  this  cause.  Catarrhal  pneumonia  may  set  in  at  any 
stage  of  the  course  of  measles.  Where  it  begins  early  it  usually  delays  or 
disturbs  the  eruption  and  leads  to  its  irregular  development  or  disposition. 
Where  it  begins  late  it  may  actually,  though  it  does  not  usually,  cause  the 
eruption  to  suddenly  disappear. 

Catarrhal  pneumonia  is  commonly  announced  by  a  more  or  less  rai>i(l  rise 
of  temperature,  increase  in  the  frequency  of  the  pulse,  and  rapidity  of  respi- 
ration. Dyspnoea  is  at  times  intense.  There  is  pallor  of  the  face,  which 
soon  shows  signs  of  cyanosis  about  the  lips.  There  is  rapid  play  of  the  alse 
nasi.  Respiration  seems  often  almost  too  quick  to  count — the  "  breath  flies." 
The  pulse  cannot  keep  up  with  it.  Its  relation  to  the  pulse  must  be  men- 
tioned later  on.  The  supra-  and  infraclavicular  spaces,  the  jugulum,  the  inter- 
costal spaces,  the  epigastrium,  are  deeply  drawn  in  with  each  act  of  ins])iration 
as  if  by  some  powerful  internal  suction  force.  The  vesicular  murmur  is 
drowned  under  the  abundant,  diffuse,  dry,  and  moist  rales.  Bronchial  respi- 
ration may  be  sometimes  detected,  along  with  dulness  to  percussion  in  the 
lower,  occasionally  also  in  the  middle,  lobes,  especially  at  the  posterior  inferior 
aspect  of  the  chest. 

Any  elevation  of  temperature  after  the  entire  disappearance  of  the  eruption 
should  at  once  excite  the  suspicion  of  broncho-pneumonia.  This  is  the  time 
at  which  this  complication  most  frequently  occurs — that  is,  during  the  period 
of  resolution — and  \\\q  complication  assumes  gravity  in  direct  correspondence 
with  the  age  of  the  patient.     In  sucklings  it  is  almost  universally  fatal.     The 


AByOIUIITIES,    COMPLKWriOXS,    AXD    SfJQUEL.E.        247 

heart  is  rarely  affected  either  in  the  course  or  se(][iience  of  measles,  yet  cases 
have  been  rejiorted  of  endocarditis,  myocarditis,  and  pericarditis — the  last 
sometimes  with  suppuration — by  Rilliet,  Barthez,  J5ouillaud,  and  Thomas. 

Com])lications  on  the  part  of  the  digestive  system  are  very  frequent. 
Sometimes  stomatitis  develops,  or  various  mycoses  may  occur  in  the  mouth, 
chiefly  in  neglected  cases.  The  tongue  presents,  as  a  rule,  only  the  furred 
appearance  that  belongs  to  all  intense  or  febrile  processes.  It  very  rarely 
displays  that  enlargement  of  the  fungiform  papillte  so  commonly  observed  in 
scarlet  fever. 

As. in  all  infections,  the  invasion  may  open  with  vomiting.  Distress  on  the 
part  of  the  stomach  is,  however,  much  uiore  infrequent  in  measles  than  in  scar- 
let fever,  from  the  fact  that  the  toxaemia  of  measles  is  so  much  less.  A  much 
more  frequent  complication  is  that  form  of  intestinal  catarrh  which  shows 
itself  in  diarrhoea.  Certain  epidemics  are  characterized  by  the  frequency,  and 
at  times  the  severity,  of  diarrhoea.  The  discharges  may  become  so  profuse  as 
to  lead  to  rapid  prostration,  or  in  some  cases  tormina  and  tenesmus  with  dis- 
charge of  blood  impart  a  dysenteric  character  and  may  lead  to  raj)id  collapse. 
As  a  rule,  however,  the  intestinal  catarrah  is  light  and  vields  readilv  to  treat- 

7  7  ~  •  ». 

meut  and  to  time.  Nephritis  is  rare  :  Kassowitz  reported  a  number  of  cases. 
The  urine  showed  albumin,  blood,  and  casts,  and  there  was  dropsy  in  the  clini- 
cal history.  Nephritis  is,  however,  as  rai'c  in  measles  as  it  is  common  in  scar- 
let fever.  Loeb  called  attention  to  the  fiict  that  propeptone  may  be  found  in 
the  urine  of  measles.  Propei)tone  (hemi-albuminose)  is  a  mixture,  according 
to  KUhne  and  Chittenden,  of  four  different  albuminoid  bodies  like  serum, 
albumin,  and  globulin.  It  is  deposited  by  heat  and  nitric  acid,  but,  unlike 
them,  only  after  the  process  of  cooling.  Propeptone  occurs,  however,  in  so  many 
and  such  varied  diseases  as  to  have,  at  present  at  least,  no  diagnostic  value. 

Complications  on  the  part  of  the  nervous  system  are  fortunately  very  rare. 
In  very  young  or  very  sensitive  children  the  disease  is  not  infrequently 
announced  by  epileptiform  convulsions.  Headache  belongs  to  the  fever  as 
well  as  to  the  catarrh.  Somnolence,  sopor,  stupor,  light  delirium,  occur  in  the 
height  of  fever  without  exciting  any  especial  apprehension.  Yet  graver  symp- 
toms have  been  recorded.  Strabismus,  tetanic  contractions,  cataleptic  states, 
maniacal  attacks,  have  been  observed  in  exceptional  cases.  It  is  essential  here 
to  bear  in  mind  the  relation  between  measles  and  tuberculosis.  JSIany  of  tliese 
cases  of  grave  cerebral  complication  are  expressions  of  basilar  meningitis. 
With  its  intense  hyperocmias,  especially  in  the  lungs,  measles  often  awakens 
quiescent  bacilli,  and  liberates  them  from  the  bronchial  glands  to  be  distrib- 
uted over  the  body.  Measles  is,  in  fact,  the  most  frequent  exciting  cause  of 
tubercular  meningitis. 

Comi)lications  on  the  part  of  the  organs  of  the  special  senses  concern  more 
particularly  the  eye  and  ear.  Measles  is  often  announced  by  conjunctivitis. 
Photophobia  and  pain  in  the  eyes  belong  among  the  earliest  signs  of  llic  dis- 
ease. Extension  of  this  process  t(t  the  deeper  structures  may  lead  to  danger- 
ous  lesions:    ulcerative   keratitis,   kera(o-malacia,   irido-cyclitis,   and    plithisis 


248  MEASLES. 

buibi  have  been  recorded,     Tobeitz  calls  attention  to  the  evil  influence  exerted 
by  measles  upon  previous — /.  e.  old  chronic  or  subacute — affections  of  the  eye. 

The  ear  is  by  no  means  so  frequently  affected  as  in  scarlet  fever.  In  many 
cases,  however,  aural  disease  assumes  prominence.  Cordies  considers  the  affec- 
tion as  a  simple  catarrh  of  the  cavity  of  the  drum,  which  is  the  result,  accord- 
ing to  Tobeitz,  of  direct  extension  of  the  rubeolar  process  from  the  throat 
through  the  Eustachian  tubes.  Otitis  media  may  ensue,  with  perforations  of 
the  membrane  of  the  drum.  The  aural  affections,  when  they  occur,  are  usually 
milder  and  less  destructive  than  those  of  scarlatina.  In  his  latest  report  Blau 
calls  attention  to  the  necessity  of  the  early  recognition  of  aural  disease  in 
measles.  Measles  is,  he  declares,  the  cause  of  2  to  10  per  cent,  of  all  dis- 
eases of  the  ear,  and  of  8  to  10  per  cent,  of  all  cases  of  suppurative  otitis 
media.  Affections  of  the  labyrinth,  due  to  the  invasion  of  pathogenic  micro- 
organisms in  the  course  of  measles,  have  been  studied  and  reported  by  Moos. 
Particulars  here  belong  to  the  domain  of  aural  pathology. 

Any  of  the  various  complications  of  measles  may  become  sequels.  They 
may  survive  the  natural  duration  of  the  disease,  be  ])rotracted  into  conva- 
lescence, or  may  develop  after  convalescence  has  been  established.  The  various 
affections  of  the  eye  and  ear,  ulcerative  processes  of  the  skin,  caries  of  carti- 
lages and  bones,  as  of  the  nose  and  alveolar  processes  of  the  jaw,  set  in  in  cer- 
tain cases,  or  the  hgemorrhagic  diathesis  may  be  imprinted  upon  a  case  in  the 
course  or  convalescence  of  the  disease.     Pertussis  is  very  wont  to  supervene. 

The  coincidence  of  whooping  cough  and  measles  has  long  been  noticed,  and 
the  relation  of  these  diseases  to  each  other  is  rather  intimate.  The  occurrence 
of  whooping  cough  in  the  course  of  measles  or  the  development  of  measles  in 
the  course  of  whooping  cough  intensely  aggravates  a  prognosis  which  might 
be,  and  is,  as  a  rule,  naturally  mild  for  either  disease  alone.  These  cases  are 
exceedingly  prone  to  the  develojmient  of  more  persistent  diseases  of  the  lungs. 
Not  infrequently  they  more  directly  and  quickly  take  life  by  exhaustion  and 
collapse. 

The  sequels  at  all  times  most  to  be  feared  are  broncho-pneumonia  and 
tuberculosis.  In  a  very  delicate  or  debilitated  child,  esjiecially  in  ev^ery  case 
brouglit  up  in  the  atmosphere  of  infection,  the  danger  of  these  diseases  is  immi- 
nent, and  the  symptoms  which  announce  the  advent  of  either  are  awaited  with 
apprehension.  At  any  time  during  the  course  of  the  ordinary  bronchitis  of 
measles  the  infection  may  extend  to  involve  the  minuter  bronchi  and  air-cells, 
and  the  complication  announces  itself  at  times  so  insidiously  as  to  escape  rec- 
ognition. The  increase  in  the  frequency  of  respiration  is,  as  stated,  a  most 
frequent  ])recursor.  The  respirations  increase  to  40,  50,  60,  or  even  80,  in 
tlie  minute — an  increase  out  of  all  proportion  to  the  rapidity  of  the  pulse. 
The  ])ulse-res])i ration  ratio  becomes  1  to  2  instead  of  1  to  4 — a  much  more 
significant  factor  in  the  development  of  pneumonia  than  mere  increase  of 
frequency  alone.  The  respiration  becomes  as  shallow  as  short.  A  child  is 
incapable  of  sustained  effort.  The  child  at  the  breast  must  frequently  release 
its  hold  to  breathe.     It  loses  the  ability  to  make  a  continuous  crv.     Children 


niA  GXOSIS.  249 

that  may  continue  to  nurse  uninterruptedly  or  may  utter  a  prolonged  cry  have 
no  catarrhal  pneumonia.  Henoch  makes  a  fine  critical  comment  in  saying 
that  "  it  is  a  good  sign  when  the  child  makes  the  physician  wait  to  hear  its 
respirations  in  an  auscultation  of  the  chest."  The  physician  may  become 
reconciled  to  the  loss  of  time  in  this  investigation. 

Attention  must  be  paid  to  these  factors,  because  the  physical  signs  of  this 
complication  or  sequel  are  so  delective.  They  may  often  not  be  dissociated 
from  the  signs  of  finer  bronchitis,  at  least  not  until  retraction  of  the  inter- 
costal spaces  and  the  sinking  in  of  the  spaces  about  the  clavicle  and  the 
epigastrium  indicate  occlusion  of  the  lungs.  Signs  or  absence  of  signs  in 
the  islets  and  tracts  of  condensation  of  catarrhal  ]>ncumonia  are  alike  drowned 
under  the  universal  moist  and  dry  rales  of  diftuse  bronchitis.  So  much  more 
important  become  the  studies  of  the  temperature.  Any  sustained  elevation 
of  temperature  after  the  eruption,  or  any  evening  exacerbation  of  temperature 
in  the  course  of  convalescence,  should  excite  the  suspicion  of  broncho-pneu- 
monia or  tuberculosis.  The  skin  often  feels  hot  in  these  cases.  The  mother 
calls  attention  to  the  heat  of  the  skin,  or  the  physician  is  struck  by  it  on 
application  of  the  hands  or  more  especially  of  the  side  of  the  face  in 
auscultation.  Elevations  of  temperature  not  so  marked,  noticed  more  espe- 
ciallv  or  perhaps  exclusively  in  the  evening,  indicate  the  insidious  develop- 
ment of  tuberculosis ;  and  this  indication  assumes  all  the  more  value  in  the 
presence  of  anorexia  and  progressive  emaciation.  The  child  does  not  gain 
strength  ;  it  becomes  peevish  and  fretful ;  toward  evening  is  excitable,  difficult 
to  put  to  sleep,  seems  disturbed  in  its  dreams,  continues  to  cough,  always  of 
course  without  expectoration,  sweats  at  night,  shows  later  perha])s  some 
diarrluea  and  marasmus :  this  is  the  history  of  a  developing  tuberculosis. 

Above  all  other  diseases,  as  stated  already,  measles  liberates  tubercle  bacilli 
from  bronchial  glands.  This  is  probably  the  true  relation  of  these  diseases. 
The  primary  infection  is  a  thing  of  the  past.  Penetration  to  the  bronchial 
glands  has  been  favored  by  coddling,  by  the  house  climate,  by  various  medi- 
cations, by  the  administration  of  cough-mixtures  or  opiates,  under  the  cover 
of  which  the  disease  has  secreted  itself  in  the  recesses  of  the  lungs — to  wit, 
the  bronchial  glands.  Measles,  with  its  hyperaemia  and  its  bronchial  and 
pulmonary  congestions,  irrigates  the  soil,  swells  the  glands,  and  arouses 
dormant  or  quiescent  seed  into  active  life.  Ziemssen  long  ago  called  attention 
to  the  revelations  of  the  laboratory  with  reference  to  cervical  glands,  in  that 
they  so  often  contain  tubercle  bacilli  hitherto  quiescent ;  and  the  same  con- 
dition has  been  revealed  of  the  bronchial  glands,  which  may  be  called  nurture 
.soils  of  the  tubercle  bacillus. 

Diag-nosis. — The  diagnosis  is  easy  as  a  rule.  The  prevalence  of  an 
epidemic  or  existence  of  other  cases,  escape  from  attack  hitherto,  are  points 
in  circumstantial  evidence.  Measles  is  din'crentiated  fruni  a  simple  catarrh 
or  a  corvza  bv  its  higher  temperature,  by  the  eiiMuthem  on  llic  secdud  or  third 
day,  and  by  the  exanthem  on  the  loiiith  day  ;  iVoin  hay  fever  by  the  period 
of  occurrence  and  the  history  of  repeated  attacks  of  liay  fever,  as  well  as  by 


250  MEASLES. 

the  eruptions  of  measles;  from  simulating  drug  eruptions,  as  from  copaiba, 
quinine,  and  the  various  antipyretics,  by  the  history  of  the  case  and  the  imme- 
diate supervention  of  these  eruptions  without  })revious  coryza ;  from  roseola 
by  the  more  uniform  redness,  of  lighter  color,  more  limited  range,  but  shorter 
duration,  with  the  absence  of  fever  characteristic  of  this  affection,  if  this  affec- 
tion may  indeed  be  specialized.  Papular  erythema,  which  may  coarsely 
resemble  measles  in  the  face,  is  distinguished  by  its  localizations  elsewhere, 
upon  the  forearms  and  backs  of  the  hands  and  feet,  as  well  as  by  the  absence 
of  fever,  catarrh,  and  bronchitis. 

Measles  must  be  separated  from  typhus  fever.  The  distinction  seldom 
comes  in  question,  because  typhus  occurs  only  in  certain  places,  and  is,  in 
general,  on  the  road  to  extinction.  Typhus  fever  in  itself  closely  resembles  a 
bad  case  of  measles,  in  that  the  disease  is  so  contagious,  the  liability  so  uni- 
versal, and  in  that  the  eruptions  may  be,  at  first  at  least,  much  alike.  Typhus 
fever,  like  measles,  begins  suddenly,  often  in  the  midst  of  perfect  health. 
There  is  from  the  start  more  profound  prostration  in  typhus,  and,  with  the 
very  inception  of  the  disease,  overshadowing  symptoms  of  mental  dulness, 
drowsiness,  sopor  deepening  into  stupor,  which  readily  passes  over  into  coma. 
This  is  the  cloud  about  the  brain  which  has  given  the  name  to  the  disease. 
It  is  present  in  only  the  worst  cases  of  measles.  Typhus  has  no  exanthem 
and  no  catarrh.  The  eruption  of  typhus  appears  on  the  third  day,  first  upon 
the  chest,  to  extend  thence  over  the  entire  body,  but  to  spare  always  or  nearly 
always  the  face.  A  peculiarity  in  the  eruption  of  typhus  fever  is  the  fact 
that  by  the  third  day  the  spots,  which  may  have  hitherto  resembled  mea- 
sles, aggregate  themselves  into  points  of  pin-head  size,  filled  with  black 
blood,  the  so-called  petechise.  Another  very  distinctive  peculiarity  is  the  fact 
that  the  temperature  does  not  fall  with  the  full  appearance  of  the  eruption. 
Disregarding  diurnal  variations  and  accidental  complications,  the  temperature 
of  typhus  maintains  itself  at  about  the  level  at  which  it  began  up  to  the 
twelfth  or  fifteenth  day — a  duration  which  is  never  seen  in  measles  except  as 
the  result  of  obvious  complications. 

Morbid  Anatomy. — The  morbid  anatomy  of  measles  does  not  differ  much 
from  that  of  the  other  exanthematous  diseases.  What  studies  have  been  made 
concern  chiefly  the  changes  found  in  the  skin  and  the  condition  of  the  lungs 
in  pulmonary  complications.  Neumann  found  the  vessels  of  the  skin  dilated 
and  hypersemic,  crowded  in  the  upper  portions  of  the  cutis  with  round  cells. 
Sweat-glands,  which  were  also  dilated,  were  invested  in  the  same  way,  their 
coils  and  ducts  packed  with  thickly-crowded  round  cells.  Round  cells  accu- 
mulated also  about  the  sebaceous  glands  and  insinuated  themselves  between 
the  muscle-cells  in  the  skin.  This  inflammatory  process  distinguishes  itself  in 
measles  by  its  more  superficial  character.  The  upper  layers  of  the  skin  were 
affected  rather  than  the  deeper  layers,  as  in  scarlatina.  Gerhardt  and  Coyne 
studied  the  changes  observed  in  the  larynx.  They  could  still  discover  evi- 
dences of  catarrhal  affection,  swelling  and  thickening,  and  desquamation  of 
the  epithelium,  and  in  some  cases  suppuration,  as  in  the  conjunctiva.     Coyne 


PROGNOSIS.— TREA  TMEXT.  251 

distinguished  the  affection  of  tile  larynx  as  an  erytliematous  laryngitis.  He 
found  it  in  connection  with  capillary  hypcrffimia  and  with  accuniulation  of 
white  blood-corpuscles  about  the  glands  and  vessels.  The  epithelium  had 
been  often  more  or  less  denuded,  and  the  interglandular  spaces  filled  with 
numerous  lymph-corpuscles. 

Tobeitz,  as  the  result  of  his  investigations  of  the  pneumonic  process, 
observed  the  disease  to  start  always  from  the  finest  bronchi  in  invasion  of  the 
air-cells.  The  affection  differed  in  no  way  from  the  broncho-pneumonia  or 
ciitarrhal  pneumonia  originating  in  the  course  of  any  descending  bronchitis. 
The  cellular  elements  exuded  are  excessively  prone  to  decay.  Bartels  had 
made  all  these  observations  before.  The  hypersemia,  with  caseous  degenera- 
tion of  the  bronchial  glands  and  liberation  of  their  contents,  more  especially 
of  tubercle  bacilli,  has  already  been  sufficiently  described. 

Black  measles  showed  the  changes  in  the  blood  and  parenchyma  of  organs 
to  be  seen  in  all  cases  of  grave  infection,  more  especially  in  true  typhus. 

Prognosis. — The  prognosis  in  general  is  favorable.  The  mortality  of 
measles,  •per  se,  is  almost  nil.  Death  seldom  or  never  occurs  directly  from 
the  disease,  but  from  complications,  previous  debility,  and  bad  surroundings. 
Thus,  Pott  found  as  the  cause  of  death  pneumonia  and  capillary  bronchitis  in 
21,  and  croup  in  3,  of  24  cases.  The  mortality  of  the  disease  in  hospital  and 
tenement-house  practice  is  quite  different  from  that  of  private  practice.  It  is 
not  uncommon  to  observe  a  mortality  of  30  per  cent,  under  bad  surroundings, 
and  the  range  would  be  still  higher  if  it  included  the  subsequent  cases  of  tuber- 
culosis which  have  come  to  light  in  consequence  of  measles.  The  mortality 
stands  also  in  quite  direct  relationship  to  the  age  of  a  child,  and  diminishes 
from  50  per  cent,  under  two  to  15  above  this  period.  The  ravages  of  the 
disease  among  savages,  as  among  our  own  Indians,  were  due  wholly  to  lack 
of  sanitation. 

Treatment. — Prophylaxis  is  almost  impossible.  Sickly,  debilitated,  more 
especially  tuberculous,  children  should  be  removed  from  infected  houses.  The 
liability  of  infection  by  third  persons  and  things  is  by  no  means  so  great  as  in 
scarlatina  ;  hence  the  necessity  of  withholding  other  members  of  the  family 
such  a  length  of  time  from  attendance  at  school  and  association  with  others 
is  not  so  imperative. 

The  treatment  is  purely  expectant  and  symptomatic.  Full  and  free  ven- 
tilation at  a  temperature  of  70°  F.,  a  night-gown  without  under-wear,  light 
but  sufficient  bed-covers,  absolute  cleanliness,  water  and  milk  ad  libitum,  sup- 
ply the  requisites  of  treatment  for  an  average  case. 

Fever  above  103°  F.  is  best  controlled  by  warm  baths,  which  may  be 
gradually  cooled,  or  by  the  occasional  administration  of  phenacetin  in  doses 
of  from  3  to  5  grains,  more  especially  in  relief  of  associated  nervous  distnvss. 
Burning  or  itching  of  the  skin  is  best  relieved  by  warm  baths,  with  subsequent 
anointment  with  vaseline  or  cocoa  butter.  Photophobia  calls  for  smoked 
glasses  or  shading  of  the  eyes  in  the  disposition  of  ihf  ifcd  or  screens,  rather 
than  for  darkening  of  the  room,  an  (.lijcctioMablc  j)rocedure.     A  drop  or  two 


252  MEASLES. 

of  a  solution  of  morphine  containing  4  grains  to  the  half  oance  or  of  atropine 
(1  grain  to  the  ounce)  allays  any  extreme  irritation  of  the  eyes ;  smearing  the 
edges  of  the  lids  with  an  ointment  of  hydrargyrum  oxiduni  flavum  (gr.  v.  to 
^ss  of  ungueutum  petrolei)  will  usually  prevent  or  cure  blepharitis  marginalis 
and  keratitis.  Simple  pure  vaseline  or  boric-acid  ointment  (gr.  xv  to  §ss), 
snuifed  into  the  nose,  will  generally  relieve  the  sense  of  dryness  and  irritation 
in  the  nose  and  throat.  The  instillation  of  hot  water  or  of  a  drop  or  two  of 
the  solution  of  atropine  (gr.  j  to  5J)  will  often  quiet  earache.  Evaporation  from 
a  piece  of  cotton  saturated  with  chloroform  held  close  to  the  meatus  is  often 
equally  effective.  Gastric  distress  and  vomiting  may  require  cracked  ice,  sips  of 
hot  water,  lime-water,  and  milk  (in  proportion  of  one-third),  bismuth  (.^ss  to  sj), 
or  chloral  (2  to  5  grains),  rectal  injections  of  sodium  bromide  (gr.  x— xxx  to 
f  ^ij  of  water),  or  of  chloral  (gr.  v-x  to  5J  of  water).  Few  cases  of  vomiting 
from  any  cause  will  resist  chloral  if  its  absorption  can  be  secured. 

Nervous  symptoms  may  call  for  sodium  bromide  in  doses  of  10  to  30  grains 
largely  diluted,  or  from  5  to  10  grains  of  chloral  or  phenacetin  suffice  for  a 
lighter  case.  Haemorrhage  and  prostration  demand  alcohol,  best  given  in  the 
form  of  brandy;  black  coifee;  turpentine,  in  doses  of  5  to  15  drops,  briskly 
stirred  in  a  wineglass  of  milk  ;  or  nitro-glycerin,  in  doses  of  1  drop  of  a  1  per 
cent,  solution,  in  whiskey  and  water ;  possibly  opium  (best  in  the  form  of  the 
camphorated  tincture,  in  doses  of  5  to  40  drops),  or  codeine,  in  doses  of  |-  to  ^^ 
of  a  grain,  may  substitute  morphine  for  more  continued  use;  carbonate  of 
ammonium,  in  doses  of  5  to  10  grains,  in  milk  ;  ergotin  or  preferably  sclerotinic 
acid,  in  doses  of  from  ^  to  |-  a  syringeful,  may  be  required.  The  syrup  or 
wine  of  ipecac,  to  which  may  be  added,  if  necessary,  a  small  quantity  of 
Dover's  powder,  preferably  in  the  form  of  a  syrup,  suffices  to  restrain  any 
excess  of  cough.  The  following  is  a  good  prescription  for  a  child  in  relief 
of  cough  : 

I|ij.  Apomorphin.  hydrochlorat.,  gr.  ss  ; 

Acid,  hydrochlor.  dil.,  gtt.  x  ; 

Syrup.,  |ss ; 

Aquse  menthse  piper.,  ^jss. — M. 
Sig.  Teaspoonful  every  two  or  three  hours. 

Diarrhoea  requires  at  first  no  control.  I^ater,  as  the  discharges  become 
more  abundant  or  colliquative,  it  may  be  restrained  by  bismuth,  to  which  may 
be  added  if  necessary  a  drop  or  two  of  tincture  of  opium.  An  improvement 
on  a  time-honored  remedy  may  be  written  as  follows  : 

^,.  Tinct.  opii,  gtt.  xl-3;j ; 

Acid,  hydrochlor.  dilut.,  gtt.  xl ; 

Aquse  camphorse,  ad  siv. — M. 

Sig.  A  tea-  to  a  dessertspoonful  every  two  to  four  hours. 


TREA  TMEXT.  25^ 

Broncho-pneumonia  calls  for  stimulation  of  tlie  respiratory  centres  as  well 
as  of  the  heart.  These  centres  are  best  reached  by  warm  baths  with  cold 
ati'usions  to  the  head.  A  rapid  respiration,  a  quick  pulse,  cold  surface,  somno- 
lence, and  delirium  call  for  baths  and  baths,  repeated  baths  with  cold  affusions, 
together  with  the  use  of  the  analeptics — camphor,  benzoic  acid,  ether,  musk, 
nitro-glycerin,  caHeine,  and  brandy. 

Gangrene  of  the  skin,  noma,  ulcerative  processes,  caries  of  bone,  are  best 
treated  with  caustics,  carbolic  acid,  solutions  of  corrosive  sublimate,  the  actual 
cauterv,  or  applications  of  iodoform.  In  all  these  cases  alcohol  must  be  ad- 
ministered abundantly. 

Cod-liver  oil,  ]Mire  or  with  malt  extract,  iron,  arsenic,  out-(K»or  air,  fresh 
air,  for  the  inlander  especially  sea-side  and  mountain  air,  with  good  food, 
pleasure,  and  peace  of  mind,  are  the  best  reconstruct ives  during  and  after 
convalescence. 


RUBELLA. 

By  JAMES  T.  WHITTAKER. 


Definition. — A  specific,  feebly  contagious,  acute  infection  of  short  dura- 
tion, characterized  by  the  absence  of  prodromata,  the  presence  of  an  eru})tion 
simulating  that  of  true  measles,  faucial  catarrh,  and  enlargement  of  the  lym- 
phatic glands. 

Synonyms. — Rubella,  diminutive  of  rubeola,  from  ruber,  red ;  R5thelu, 
diminutive  of  roth,  red  ;  German  measles,  French  measles,  because  described 
by  German  and  French  observers,  really  first  isolated  by  an  English  physi- 
cian ;  Hybrid  measles  ;  False  measles,  etc. 

The  word  "  rubella,"  which  seems  to  have  been  first  recommended  by 
Veale  (1866),  soon  met  with  general  acceptance.  The  Germans  still  call  the 
disease  rubeola,  our  term  for  measles,  which  they  still  call  raorbilli.  The 
French  distinguish  it  as  rubeole,  in  distinction  from  rougeole,  true  measles. 
The  popular  designation  in  Germany  is  rotheln,  a  term  recognized  by  scholars 
everywhere,  and  as  commonly  used  by  writers  in  Germany  as  is  measles  in 
our  country.  Rotheln  can  never  be  adopted  among  English-speaking  people. 
The  sound  of  o  with  the  umlaut  cannot  be  translated.  The  name  is  therefore 
too  distinctly  racial  for  universal  acceptance.  Rubella  means  exactly  the  same 
thing.  No  valid  objection  can  be  urged  against  the  name  rubella  as  indicating 
a  diminutive  of  rubeola,  and  as  permitting,  however  akin  to  rubeola,  the 
recognition  of  an  independent  malady.  The  universal  acceptance  of  the 
term  varicella,  which  has  a  similar  relation  to  variola,  establishes  a  perfect 
precedent  for  rubella  and  rubeola. 

Bergen,  who  described  it  among  the  roseolse  in  1752,  first  maintained  the 
view  that  it  should  be  separated  from  measles  and  scarlet  fever,  but  it  was 
reserved  for  an  English  physician,  Maton,  in  1815  to  establish  the  individu- 
ality of  the  disease  as  based  chiefly  upon  the  observation  that,  though  self- 
protective,  in  that  one  attack  confers  future  immunity,  it  does  not  protect 
against  either  measles  or  scarlatina.  Nor  do  these  diseases  protect  against 
rubella. 

There  was  almost  up  to  the  present  time — in  fact,  there  is  yet — much  lack 
of  harmony  regarding  the  true  nature  of  this  affection.  K5stlein  in  1865 
still  considered  rubella  a  variety  of  measles.  Striimpell,  on  the  other  hand, 
declares  that  only  they  who  have  never  seen  it  deny  the  existence  of  the  dis- 
ease as  an  independent  malady.  Heim  looked  upon  it  as  an  anomalous  scar- 
latina.    Hildebrandt  regarded  it  as  an  intermediate  or  hybrid  form  of  measles 

264 


ETIOLOGY.  255 

and  scarlatina — a  view  whicli  lnul  singular  fascination  for  many  authors, 
including  such  close  observers  as  Gintrac  and  Hebra.  Barthez  and  Rilliet, 
Eniiuinghaus,  Gerhardt,  Griffith,  Hardaway,  Murchison,  Roger,  Steiner, 
Thomas,  Thierfeldcr,  Trousseau,  AVilson,  all  acknowledge  the  individuality 
of  rubella,  while  Faggc,  Henoch,  and  Stewart  still  deny  it.  It  is  certain  that 
epidemics  of  rubella  may  prevail  apart  from  epidemics  of  measles  and  scar- 
latina. It  is  also  established,  as  stated,  that  an  attack  of  either  scarlatina  or 
measles  gives  no  immunity  from  rubella.  Again,  an  attack  of  rubella  does 
not  exempt  the  individual  from  attacks  of  measles  and  scarlet  fever.  AVhile 
more  closely  allied  to  measles  than  to  any  other  disease,  it  is  not  hence  to  be 
regarded  as  a  subvariety  of  measles,  but  as  a  distinct  and  separate  affection 
whose  cause  is  sui  generis.  Rubella  stands  in  relation  to  rubeola  not  as  vari- 
oloid, but  as  varicella,  to  variola.  It  certainly  differs  from  both  measles  and 
scarlet  fever  in  its  contagiousness,  mode  of  invasion,  symptomatology,  dura- 
tion, and  decline. 

Etiology. — Though  much  less  contagious  than  measles,  and  hence  much 
less  frequent,  the  disease  is  decidedly  more  prevalent  than  commonly  believed. 
IVIany  cases  are  mistaken  for  measles,  and  most  of  the  so-called  successive  or 
repeated  attacks  of  measles  are  really  rubellse.  Rubella  is  certainly  distinctly 
contagious,  and  the  contagium  increases  in  virulence  with  the  number  of  cases 
and  with  defective  hvgiene.  As  to  the  intensitv  of  its  contagion,  authorities 
differ.  Nymann,  Picot,  and  Arnold  think  it  but  feebly  contagious  ;  Thomas 
and  Bonrneville  regard  it  as  less  contagious  than  measles  ;  Jacobi  and  Squire 
consider  it  eminently  contagious,  and  maintain  that  the  contagiousness  is  man- 
ifest before  the  appearance  of  the  eruption  and  persists  for  several  weeks  after 
its  disappearance ;  Atkinson  claimed  that  it  is  less  contagious  than  measles, 
and  Edwards  concludes  that  it  is  one  of  the  most  contagious  of  all  the  erup- 
tive fevers;  Griffith  states  that  37  of  100  children  in  a  "home"  which  he 
attended  contracted  the  disease,  notwithstanding  the  most  prom))t  and  careful 
isolation;  and  Edwards  quotes  from  Hatfield  that  110  of  196  inmates  of  an 
asylum  suffered  from  the  disease.  The  disease  is  propagated  also  by  third 
persons  and  by  things.  The  bedding  of  steerage  passengers  has  been  known 
to  conceal  and  convey  contagion  for  a  long  time. 

From  the  nature  of  the  disease  the  cause  of  rubella  must  be  a  micro-organ- 
ism, but  the  specific  structure  has  not  yet  been  isolated.  Micrococci  have 
been  observed  in  the  blood,  but  without  any  other  evidence  of  positive  rela- 
tionship. 

Rubella  occurs  at  all  ages,  rarely  in  inliuicy  ;  75  per  cent,  of  cases  occur 
before  the  age  of  fifteen.  Childhood  is  thus  the  period  of  greatest  liai)ility, 
but  susceptibility  to  it  is  so  much  less  than  to  measles  that  the  majority  of 
people  escape  it  throughout  life.  Sholl  saw  the  enq)ti(m  in  a  newborn  child  ; 
Steiner  and  Roth  report  cases  in  infants  under  six  mouths.  These  cases  arc 
regarded  as  exceptions.  Attacks  in  adtdt  life  are  ihikIi  more  frequent  than 
attacks  of  measles — first,  because  the  susceptibility  is  not  so  universal,  so  that 
childhood   often  escapes  it  ;  and  sccoudly,  because  epidemics  prevail  :i(    much 


256  RUBELLA. 

longer  intervals.  Adnlts  have,  however,  immunity  in  high  degree.  Kasso- 
witz  observed  but  five  cases  in  adult  life.  The  range  of  liability  in  regard  tO' 
age  is  illustrated  by  the  possibility  of  attack  in  advanced  life.  Seitz  recorded 
a  case  in  a  woman  aged  seventy-three. 

Symptoms  and  Course. — The  period'  of  incubation,  two  to  three  weeks, 
is  uncommonly  long,  while  the  stage  of  invasion  or  prodromal  stage,  half  a 
day  to  one  day,  is  uncommonly  short.  An  initial  chill  is  exceptional  ; 
malaise,  pain  in  the  head,  back,  or  joints ;  anorexia,  rarely  vertigo ;  very 
rarely  more  pronounced  distress  on  the  part  of  the  nervous  system, — more  or 
less  immediately  usher  in  the  eruption  and  affection  of  the  mucosae  and  glands. 
Not  infrequently  the  appearance  of  the  eruption,  totally  unprefaced  by  any 
fever,  is  the  first  sign  of  disease.  The  eruption  appears  as  minute  rose-red 
maculae,  discrete  or  confluent,  "  like  dark  red  ink  pen-points  in  white  blotting- 
paper,"  on  the  forehead  and  temples,  spreading  quickly  over  the  rest  of  the 
face,  neck,  and  trunk,  to  reach  its  full  efflorescence  and  begin  to  fade  in 
twenty-four  or  thirty-six  hours.  By  the  third  day,  as  a  rule,  all  signs  of 
eruption  disappear  without  desquamation.  Coincident  with  the  eruption  is  a 
rise  of  temperature  to  99°-101°  F.,  very  exceptionally  to  102°-103°  F. 

Hypersemia  of  the  conjunctiva,  with  photophobia  and  epiphora,  of  the  nasal 
mucous  membrane,  with  a  sense  of  dryness  and  irritation,  with  sneezlno^  or 
with  increased  discharge,  more  especially  hyperaemia  or  visible  enanthem  of 
the  fauces  and  pharynx,  may  precede  the  eruption  during  the  stage  of  inva- 
sion when  it  occurs,  to  coexist  with  the  eruption  and  remain  after  it  as  late  as 
the  fourth  day  of  the  disease. 

Affection  of  the  glands  constitutes  a  much  more  distinctive  feature  of 
rubella.  The  cervical  submaxillary  and  occipital  glands,  more  rarely  also  the 
glands  of  the  axilla,  elbow,  and  groins,  become  swollen  and  tender,  limiting 
the  movements  of  the  head  at  times  in  the  swelling  and  stiffness  of  the  neck. 
These  adenopathies,  Avhich  exist  in  50  to  75  per  cent,  of  cases,  disaj^pear 
entirely  in  two  or  three  days.  Abnormal  cases  show  only  an  eruption  or  only 
affection  of  the  glands. 

The  reviewer  of  the  literature  of  rubella  is  struck  with  the  variety  of 
opinions  encountered  regarding  every  feature  of  the  disease.  In  this  regard 
rubella  differs  radically  from  rubeola.  True  measles  has  a  distinct  history  and 
a  singular  uniformity  of  symptoms.  All  competent  observers  agree  in  the 
main  regarding  the  period  of  incubation,  the  stage  of  invasion,  the  character 
of  the  eruption,  etc.  The  occasional  abnormalities  and  irregularities  are  to  be 
accounted  for  by  the  condition  of  the  patient  and  the  character  of  his  surround- 
ings, rather  than  by  any  difference  in  the  nature  of  the  disease,  expression, 
order,  or  sequence  of  its  symptoms. 

In  rubella,  on  the  other  hand,  scarcely  two  observers  agree,  and  the  differ- 
ence at  times  is  so  marked  as  to  lead  to  the  belief  ^hat  different  affections  are 
being  observed  or  described.  It  is  questionable  if  the  disease  commonly 
described  as  rubella  be  a  distinct  or  single  affection.  Competent  observers, 
as  stated,  still  maintain  it  to  be  a  subvariety  or  hybrid  form  of  scarlet  fever,, 


SYMPTOMS  AND    CO  UBS E.  257 

or  more  especially  of  measles.  It  certainly  most  dearly  simulates  measles. 
The  admission  of  the  disease  as  an  entity  depends  almost  wholly  upon  its 
independence  of  measles  or  scarlet  fever.  This  fact  does  not  exclude  the  exist- 
ence of  more  than  one  malady. 

Thus  the  period  of  iucuhation  has  been  fixed  in  its  descrii)tiou  at  two  or 
three  weeks.  Griffith,  Glaistor,  Sholl  put  it  at  five  to  ten  days,  Steiner  at 
ten  to  fourteen  days,  Jacobi  at  fourteen  to  twenty-one  days,  Cotting  at  three 
weeks.  Edwards  fixes  it  at  certainly  between  ten  and  twelve  davs  :  the  short- 
est  period  recorded  in  his  experience  was  six  days,  the  longest  twenty-one. 

In  the  observation  of  the  author  the  stage  of  invasion  has  been  always  free 
of  symptoms.  Grave  symptoms  have,  however,  been  remarked  by  others. 
Smith  saw  convulsions ;  Hardaway,  delirium  ;  Priolcau,  haemorrhage  from 
the  eyes  and  ears  ;  Nymann,  vertigo  ;  and  various  eruptions  have  been  noticed 
by  others. 

The  disease  is  announced  generally  by  the  eruption,  which  appears  so  quietly 
at  times  as  to  be  noticed  for  the  first  time  in  the  morning  on  awakening  from 
sleep.  It  shows  itself  first  upon  the  fiicc,  and  spreads,  as  a  rule,  so  rapidly 
over  the  body  and  extremities  as  to  seem  to  show  itself  everywhere  at  the  same 
time.  Patterson  indeed  declares  that  it  comes  out  universally.  Occasionally  it 
is  very  sparse  and  circumscribed.  Edwards  says  that  he  has  seen  it  confined  to 
a  small  part  of  the  brow,  face,  and  neck,  and  so  scanty  as  to  have  made  a  diag- 
nosis impossible  had  it  not  been  for  the  presence  of  other  cases.  It  is  usually 
entirely  discrete,  but  becomes  confluent  at  times  on  the  face  or  upon  surfaces 
kept  warm  by  apposition,  as  in  the  flexures  of  the  joints,  about  the  groin,  etc. 
As  with  all  the  eruptions,  it  is  more  pronounced  under  hot  applications,  poul- 
tices, embrocations,  etc.  Griffith  says  that  he  saw  it  once  in  circular  bands 
about  the  leg  above  the  knee,  in  the  line  of  the  garter.  Klatsch  made  a 
similar  remark. 

The  character  of  the  eruption  diffin-s  in  every  particidar  in  the  description 
of  diffi^rent  authors.  Hcim  gives  it  the  color  of  red  ink  on  white  paper. 
Tiiomas  declares  that  it  is  not  so  red  as  that  of  scarlet  fever,  nor  so  blue  as 
that  of  measles.  It  is  usually  entirely  macular.  Aitkin  dcelares  that  it  is 
more  elevated  than  measles.  Griffith  felt  induration  like  shot  under  the  skin. 
Cases  have  been  described  as  so  closely  simulating  measles  or  scarlet  fever  as 
to  have  justified  the  designations  rubella  morbilliforme  and  rubella  scarlatini- 
forme.  Harrison,  Copeland,  and  Goodhardt  claim  that  it  may  resemble  either 
measles  or  scarlatina.  Byers,  Picot,  and  Henderson  saw  cases  where  the  erup- 
tion was  morbilhTorm  in  one  part  and  scarlatinifi>rm  in  aiiotlicr  part  (if  the 
same  patient.  Dukes  and  Kassowitz  declare  that  it  may  resemble  measles, 
and  Murchison  and  Tonge-Smith  declare  that  it  simulates  scarlet  fever.  These 
statements  are  from  Edwards,  who  made  an  exhaustive  study  of  the  authorities, 
and  adds:  "This  list  could  be  almost  iudcfiiiitc^ly  prolonged,  but  to  no  ))ur- 
pose.  Sufficient  has  been  cited  to  show  that  the  eruption  of  rubella  is  iudi'cd 
multiform  in  character." 

The  eruption  disappears,  as  a    ride,  iu  twenty-four  to  thirty -six    hours: 

Vol.  I.— 17 


258  RUBELLA. 

Emminghaus  savs  in  from  two  to  four  days ;  Klaatash,  in  from  one  to  five 
da3'S  ;  Liveing,  in  from  five  to  seven  days.  Tlie  eruption  disappears,  as 
stated  as  a  rule,  without,  or  with  but  very  sh'glit,  desquamation.  When 
present,  desquamation  is  always  furfuraceous.  Sometimes  it  is  best  marked 
in  the  throat. 

Slight  fever  to  100°-101°  F.  is  the  rule.  Exceptional  cases  show  high 
temperatures.  Haig-Brown  recorded  105°  F. ;  Davis,  106°,  with  a  hseraor- 
rhagic  eruption  and  convulsions ;  Wunderlich  declared  that  many  cases  show 
no  fever  at  all;  and  GriiBth  reported  a  case  of  extensive  eruption  marked  by 
the  complete  absence  of  fever. 

Sore  throat,  faucial  catarrh,  is  observed  in  the  majority  of  cases.  There  is 
perhaps,  more  unannimity  of  opinion  upon  this  symptom  than  upon  any  other. 
Hypersemia  of  the  throat  shows  itself  sometimes  in  an  enanthem  like  that  of 
measles.  The  infection  may  also  involve  the  larynx,  and  occasionally  the 
bronchial  tubes. 

The  most  characteristic  symptom  is  affection  of  the  lymphatic  glands.  Few 
writers — among  the  most  noted  Kassowitz — failed  to  mention  its  frequency. 
The  distinguishing  feature  of  the  adenopathy  is  the  universal  involvement  of 
the  glands.  The  cervical,  occipital,  submaxillary,  and  sublingual  glands  are 
often  all  involved.  Park  found  distinct  adenopathy  in  the  neck  and  under 
the  tongue  in  50  per  cent,  of  his  cases.  The  affection  may  extend  so  as  to 
involve,  as  stated,  the  axillary  and  even  the  inguinal  glands. 

The  diagnosis  is  made  to  rest  largely  upon  this  extensive  implication  of 
the  lymphatic  glands,  measles  rarely  showing  any  such  affection.  Scarlatina 
shows  it  as  a  rule,  but  the  swelling  is  confined  almost  exclusively  to  the  glands 
and  interglandular  tissues  below  the  jaws.  Scarlatina  never,  or  almost  never, 
affects  the  cervical  and  post-cervical  glands.  Few  observers  w^ould,  however, 
be  prepared  to  go  so  far  as  Osborn,  who  claims  as  a  pathognomonic  feature  of 
rubella — one  so  constant  in  its  occurrence,  he  says,  that  when  observed  there 
can  be  no  longer  doubt — "  an  enlargement  of  the  small  glands  just  about  the 
edge  of  the  hair  on  the  postero-lateral  sides  of  the  neck."  This  feature  was 
never  absent  in  any  case  which  he  saw. 

Gastro-intestinal  disturbance  corresponds  in  severity  rather  with  the  fever 
than  with  the  eruption.  It  is  usually  absent  or,  if  present,  but  trivial  and 
transitory.  It  is  a  rare  case  which  shows  the  intensity  of  disturbance  not 
infrequently  seen  in  measles  and  observed  as  a  rule  in  the  inception  of  scarla- 
tina.    The  "strawberry  tongue"  of  scarlet  fever  is  never  seen. 

It  is  commonly  said  that  rubella  has  neither  complications  nor  sequelae. 
This  is  true,  however,  only  of  the  average  or  milder  case,  especially  as 
observed  in  j^rivate  practice  under  favorable  hygienic  conditions.  In  hos- 
j)ital  and  tenement-house  practice  complications  are  not  so  rare,  though  they 
are  by  no  means  so  common  as  in  measles. 

Bronchitis  may  become  excessive.  Edwards  saw  pneumonia  three  times, 
Griffith  twice  in  1 50  cases.  Stomatitis,  intestinal  catarrh,  icterus,  rheumatism, 
various  eruptions,   including  pemphigus,  have  been   remarked  in  individual 


DIA  GNOSIS.— MORTALITY.  259 

cases.  Sequels  of  diphtheria,  mumps,  blepliaritis,  keratitis,  aud  otitis,  to  be 
fouud  in  the  records,  must  be  looked  upon  as  accidental.  The  light  distm-b- 
ance  produced  in  the  lungs  is  evidenced  by  the  rarity  of  subsequent  tubercu- 
losis as  compared  with  the  history  of  measles. 

Re]a])ses  and  recurrences  are  very  rare. 

Diagnosis. — As  a  rule,  the  physician  is  summoned  to  distinguish  the  erup- 
tion from  that  of  measles.  The  eruption  of  this  disease,  as  stated,  appears 
earlier,  often  without  any  previous  disorder;  is  lighter  in  color — a  rose  not  a 
raspberry  red ;  is  more  frequently  discrete,  or  M'hen  confluent  more  diiFuse,  not 
aggregated  into  patches;  disappears  completely  without  or  with  but  slight 
desquamation  in  one  to  three  days.  These  features,  in  connection  with  the 
more  pronounced  implication  of  the  throat  and  the  glandular  affections,  suf- 
ficiently distinguish  the  disease. 

Rubella  is  distinguished  from  measles,  the  only  affection  with  which  it  is 
likely  to  be  confounded,  by  the  history  or  absence  of  a  previous  attack  of 
measles,  bv  the  existence  of  other  cases,  bv  its  feebler  contagiousness,  long-er 
incubation,  shorter  invasion,  hence  earlier  appearance  of  the  eruption,  absent 
or  but  light  or  limited  affection  of  the  mucosae,  more  frequent  and  extensive 
adenopathies,  more  trivial  fever,  and  shorter  duration. 

Rubella  is  distinguished  from  scarlatina  by  the  history  of  the  individual, 
as  stated  above;  by  the  longer  incubation — two  to  three  weeks  in  rubella,  one 
day  to  one  week  in  scarlet  fever;  by  the  characteristic  intense  sore  throat  of 
scarlet  fever  in  contrast  with  the  trivial  catarrh  of  rubella ;  by  the  violence 
of  the  invasion  of  scarlatina — vomiting,  hyperpyrexia,  often  delirium  and 
convulsions,  in  scarlet  fever,  all  absent  in  rubella  ;  by  the  more  universal 
affection  of  glands  in  rubella,  more  intense  inflammation  and  tumefaction  of 
the  submaxillary  glands  only  in  scarlet  fever;  by  the  appearance  of  the  erup- 
tion, first  upon  the  face  or  iniiversally  in  rubella,  first  on  the  chest  and  neck 
with  slower  spread  in  scarlet  fever ;  by  the  disajjpearance  of  the  eruption  in 
one  to  four  days  in  rubella,  in  four  to  six  days  in  scarlet  fever;  by  the  disap- 
j)earance  of  symptoms  with  the  appearance  of  the  eruption  in  rubella,  by  the 
j)ersistence  of  symptoms  during  the  eruption  of  scarlet  fever  ;  by  the  straw- 
berry tongue  of  scarlet  fever,  absent  in  rubella;  by  the  albuminuria  and 
affections  of  the  kidney  in  scarlet  fever,  absent  in  rubella  ;  by  the  desquama- 
tion, membranous  in  scarlet  fever,  absent  or  furfuraceous  in  rubella. 

The  roseola,  adenojiathies,  and  sore  throat  of  syphilis  could  not,  on  account 
of  their  persistence,  be  long  mistaken  for  rubella,  even  in  the  absence  of  all 
history  of  primaiy  infection. 

The  diff"use  crvthemata  of  drug  eruptions — antipyretics,  coj)aiba,  chloral, 
etc. — liave  the  history  of  their  use,  and  are  unattended  by  fever,  sore  thi-oat 
or  affections  of  the  glands. 

Prophylaxis. —  Inasmuch  as  most  people  escape  riilielia,  isolation  of  eases 
ill  a  separate  room  or  story  of  the  house  is,  when  |)ractieal)le,  advisable. 

The  mortality  is  almost  nil.  In  this  regard  the  disease  has,  however,  the 
same  historv  as  measles.     Bad  surroundings  may  impart  great  gravity.     JI<.s- 


260 


RUBELLA. 


pital  and  tenement-house  practice  furnishes  a  mortality  of  3  to  10  per  cent., 
due  almost  wholly  to  complications,  chief  among  which  are  capillary  bron- 
chitis and  bn^ncho-pneuraonia. 

Treatment,  which  is  for  the  most  part  superfluous,  does  not  diifer,  when 
necessary,  from  that  of  measles. 


SMALL-POX. 

By  JAMES  T.  WHITTAKER. 


Synonyms  and  Definition. — Siiiall-pox  or  pocks  (pock,  a  bag  or  sac — i.  e. 
small  sacs);  Variola,  from  varus,  a  pimple,  a  term  applied  in  ancient  times  to 
many  eruptions,  first  limited  to  small-pox  in  the  epidemics  of  France  and 
Italy,  570  a.  d.  (Hirsch),  first  used  by  Constantinus  Africanus,  1080  A.  D. 
(Curschfeld) ;  German,  Pocken,  Blatter  (blister)  ;  French,  Petit  v6role, — is  a 
highly  contagious,  extremely  dangerous,  literally  dreaded  disease,  characterized 
by  violent  onset  with  severe  chill,  excruciating  pain  in  the  back  and  head,  by 
an  eruption  of  papules,  subsequently  converted  into  vesicles  and  pustules,  wliich 
leave  in  drying  disfiguring  pits  or  scars,  and  by  a  fever  which  remits  at  the 
period  of  papular  efflorescence  to  increase  in  the  stage  of  suppuration. 

Small-pox  has  existed  from  time  immemorial  in  India,  where  temples  were 
built  and  a  goddess  worshipped,  and  where,  more  to  the  purpose,  the  Brah- 
mins practised  inoculation  in  protection  against  it.  Accounts  of  it  in  Africa 
date  also  from  the  most  remote  antiquity,  and  the  great  susceptibility  of  the 
negro  race  lends  color  to  the  view  that  the  disease  mav  have  oriy-inated  in 
these  lands.  It  was  imported  into  China  probably  about  200  a.  d.  Galen 
speaks  of  the  prevalence  of  it  in  Rome,  160  A.  D. ;  Marius,  of  its  invasion 
of  France  and  Italy,  570  A.  d.  ;  Gregory  of  Tours,  of  its  epidemic  occurrence 
in  a  large  part  of  the  south  of  Europe,  580  A.  D, ;  and  Rhazcs  wrote  his  famous 
work  concernino;  it  in  900  A.  d.  Riiazes  declared  that  while  the  disease  had 
received  frequent  mention  in  antiquity,  up  to  his  time  "  there  liad  not  appeared 
either  among  the  ancients  or  the  moderns  an  accurate  and  satisfactory  account 
of  it,"  and  therefore  he  composed  his  discourse.  Rhazes  certainly  saw  small- 
pox and  described  its  most  striking  features,  especially  in  distinction  from 
measles. 

Small-pox  entered  England  in  1241,  Iceland  in  1306,  but  did  not  reach 
Germany  and  Sweden  until  toward  the  close  of  the  fifteenth  century.  It  was 
imported  to  America  first  in  the  West  Indies  in  1507,  exterminating  whole 
races  of  natives  ;  next  by  Spanish  troops  into  Mexico  in  1520,  where  it  carried 
off  three  and  a  half  millicms  of  j)e()ple.  In  the  United  States  it  reached  Boston 
from  Europe  in  1649,  and,  though  decimating  the  Indians  in  every  direction, 
made  l)ut  slow  progress  and  limited  ravage  aiiiung  Ihc  white  races  because  of 
the  introduction  of  vaccination  in  1799,  the  period  of  coinmcncing  Western 
migration.  Thus  it  did  not  reach  Kansas  until  18.'}7:uhI  California  until 
1850.     Epidemics  in  South  America,  first  in  1554,  corresponded  with  the  intro- 

201 


262  SMALL-POX. 

duction  of  slaves  from  Africa.  Certain  islands  of  Polynesia  remain  as  yet 
exempt. 

Small-pox  has  now  only  historic  interest.  It  is  on  the  road  to  extinction, 
and  may  occur  in  our  day  in  epidemic  proportion  only  in  uncivilized  lands. 
The  most  modern  text-books  of  medicine,  if  they  describe  it  at  all,  dispose  of 
it,  as  of  the  pest  and  other  plagues  of  ancient  times,  in  but  few  words.  Small- 
pox, as  we  see  it,  occurs  in  the  modified  form  known  as  varioloid.  Cases  of 
true  variola  become  rarer  and  rarer  every  year.  Since  the  general  introduction 
of  vaccination  small-pox  has  lost  all  its  terrors  for  those  who  recognize  its  abso- 
lute protection.  In  many  parts  of  Europe  small-pox  patients  are  no  longer 
isolated  in  pest-houses,  but  are  received  into  the  general  wards  of  hospitals, 
other  inmates  being  protected  by,  if  necessary,  fresh  vaccination.  The  dread- 
ful character  of  the  disease  in  former  times  is  evidenced  in  our  dav  in  no  way 
better  than  by  the  fear  inspired,  the  panic  created,  by  the  knowledge  of  the 
existence  of  a  case  in  a  community.  Watson  said  of  it — the  disease  may  not  be 
studied  without  reference  to  the  old  masters — "  The  horrible  asj^ect,  disfig- 
uring consequences,  and  fatal  tendency  are  so  strongly  marked  that  its  appear- 
ance has  always  been  watched  with  affright  by  mankind  in  general,  and  with 
intense  interest  by  the  philosophic  physician," 

The  havoc  which  the  disease  has  made  in  the  past  is  apparent  in  the  holo- 
caust effected  in  Mexico  and  in  the  veritable  slaughters  in  India.  In  the  two 
years  as  late  as  1874-75  half  a  million  })eople  in  the  presidencies  of  Bombay 
and  Calcutta  alone  fell  victims  to  small-pox.  In  1865,  7000  natives  died  in 
less  than  two  months.  It  constituted  7  to  9  ])er  cent,  of  the  total  mortality  in 
England  in  the  seventeenth  and  eighteenth  centuries,  and  nearly  9  per  cent, 
of  that  of  the  citv  of  Berlin  in  1783-87.  In  France  during;  tiie  whole  of  the 
eighteenth  century  3000  people  died  annually  of  small-pox.  Whole  races  of 
men  were  carried  off  in  Brazil,  one-third  of  the  population  in  Iceland  in  1707, 
two-thirds  of  that  in  Greenland  in  1734.  It  is  computed  of  the  century  pre- 
ceding vaccination  that  fifty  millions  of  people  died  in  Europe  of  small-pox. 
The  human  race  was  beaten  down  until  men  became  resigned  to  the  disease. 
Macaulay  called  it  the  most  terrible  of  all  the  ministers  of  death.  The  dan- 
ger to  life  and  disfiguration  of  the  living,  especially  loss  of  sight,  made  it,  to 
a  degree  of  which  we  can  have  now  no  coneej^tion,  the  most  dreaded  of  all 
diseases.  "There  is  no  contagion  so  strong  and  sure  as  that  of  small-pox," 
Watson  writes,  "  and  none  that  operates  at  so  great  a  distance." 

Etiology. — Susceptibility  to  small-pox  is  almost,  though  not  quite,  uni- 
versal. The  extent  of  immunity  is  difficult  to  establish  in  our  day  because 
of  the  protection  of  vaccination,  but  it  was  recognized  in  ancient  times  that 
certain  individuals  who  came  in  close  or  repeated  contact  with  the  disease 
remained  exempt  from  attack.  Three  distinguished  physicians,  Morgagni, 
Boerhaave,  and  Diemerbroeck,  were  said  to  have  enjoyed  this  immunity,  and 
Dicmerbroeck  Avas  so  struck  by  it  in  his  own  person  as  to  have  been  led  to 
believe  that  the  disease  was  but  feebly  contatjious.  The  common  Eno;lish  name 
is  said  by  one  writer  to  have  been  derived  from  the  fact  that  it  attacks  the 


ETTOLOav.  2n3 

small.  This  is  true,  but  it  is  rathor  oviJeiu'c  of  universal  sustx'ptibility. 
Though  it  spares  no  age,  siuall-pox  is  essentially  a  disease  of  ehiklhootl, 
"  interrupted  and  postponed  by  vaeeination."  Of  the  newborn,  one-third 
died  before  their  first,  one-half  before  their  fifth  year  of  lite  (Werner). 
Old  synonyms  of  the  disease  (Kinderpoeken,  Barnkoppen)  attest  this  tact. 
Of  622  persons  who  died  of  small-pox  in  Kilmarnoek  in  1728-64,  508 — 
i.  €.  92.2  })er  cent. — were  five  years  of  age  and  under ;  7  only  were  over  ten 
years  of  age,  and  the  oldest  was  but  twenty-six. 

This  exemption  of  maturity  and  age  was,  however,  due,  in  some  degree  at 
least,  to  innnunity  seeured  by  former  attack.  Accurate  statistics  disclose  the 
fact  that  the  disease  occurs  at  all  periods  of  life,  even  uj)  to  the  advanced  age 
of  sixty  and  seventy,  and  in  proportions  at  these  times  which  nearly  correspond 
to.  the  number  of  people  alive  at  this  period  of  life. 

Sucklings  enjoy  some  immunity.  Liability  grows  intense  at  the  end  of  the 
first  year  and  continues  up  to  forty,  when  it  becomes  less  marked.  Pregnancy 
and  the  puerperium  rather  invite  than  repel  the  disease.  It  may  certainly  attack 
the  foetus  in  utero  after  the  fourth  month,  and  children  have  been  born  in 
every  stage  of  the  disease.  The  greater  liability  of  these  periods  is  counter- 
balanced in  man  by  his  more  frequent  exposure,  so  that  sex  shows  no  real 
difference. 

Allusion  has  been  made  to  the  frequency  and  severity  of  the  disease  in 
ne<>;roes.  This  fact  has  been  noticed  not  onlv  in  their  own  countrv,  but  in  all 
lands  to  which  they  have  been  carried.  The  more  frequent  disfiguration 
among  the  colored  race,  which  may  be  seen  upon  the  streets,  is  due  jiartly  to 
this  cause,  but  chiefly  to  neglect  of  vaccination. 

One  attack  confers  immunity  for  the  future,  with  occasional  rare  excc[)tions, 
as  does  also  one  successful  vaccination,  with  more  frequent  exceptions.  The 
lightest  attack  protects,  as  a  rule,  for  life.  This  fact  was  proven  by  the 
results  of  inoculation,  "the  mother-])rogenitor  of  the  beneficent  vaccination." 
A  second  attack,  if  it  occur,  is  usually,  but  not  always,  milder.  Louis  X  V.  of 
France  survived  an  attack  at  the  age  of  fourteen,  but  died  of  one  at  sixty-fi)ur. 
Aitken  quotes  a  case  reported  by  Ron})el  of  three  attacks,  a  lady  of  M.  Guin- 
net,  wdio  had  it  five  times,  a  case  by  Matson  of  seven  attacks,  and  one  by 
Raring,  a  surgeon  attacked  on  every  attendance   upon  a  case. 

The  existence  of  other  infections  gives  comj)arative  inunnnity  only  during 
their  course.  The  chronic  diseases  of  the  heart,  lungs,  kidneys,  etc.  do  not 
diminish  liabilitv.  It  has  been  fitund  to  coexist  with  other  iidections — scarla- 
tina, measles,  and  j)ertussis.  Kpidemics  occur  more  fre(|ncn(ly  in  the  colder 
seasons,  partly  because  of  the  closer  contact  of  people  at  this  time,  j)artly 
because  of  the  concentration  of  the  contagiuni  in  less-ventilated  rooms. 
Boerhaave,  who  himself  never  contracted  the  disease,  first  established  it^s 
development  by  contagion. 

The  contagious  principle  of  small-j)ox  certainly  exists  in  (lie  skin,  whence 
it  is  disseminated  about  th<'  bodv  of'the  patient.  In(»cidatiou  was  formerly 
practised  wlioliv  bv  the  nialtei-  r,|'  die  disease  in  the  skin.      It  was  the  eiistom 


264 


S3IALL-P0X. 


in  China  in  the  most  ancient  times  to  introduce  the  crusts  of  small-pox  matter 
into  the  nose  in  the  process  of  inoculation,  and  in  India  to  rub  the  matter  on 
an  abraded  skin.  The  fact  of  infection  of  the  foetus,  which  is  undeniable, 
proves  that  the  poison  exists  in  the  blood.  There  is,  however,  no  proof  of  the 
existence  of  the  poison  in  any  of  the  various  secretions  or  excretions  of  the 
bodv.  Experiments  made  upon  man  date  altogether  from  ancient  times. 
These  exj^eriments  with  the  secretions  gave  negative  results.  Doubt  even  had 
been  thrown  upon  the  infectiousness  of  the  blood  until  Ziilzer  succeeded  in 
communicating  the  disease  to  a  monkey  with  the  blood  of  a  variolous 
patient. 

The  contagious  principle  has  singular  tenacity  of  life.  It  sticks  especially 
to  bedding  and  clothing,  which,  if  kept  secluded  at  a  warm  temperature,  may 
remain  infectious  for  months  and  even  years.  The  body  and  bedding  of  a  patient 
affected  with  small-pox  is  surrounded  by  the  infectious  matter  as  by  a  cloud  or 
halo.  In  a  large,  Avell-ventilated  apartment  the  danger  of  infection  on  account 
of  dilution  and  diffusion  of  the  poison  is  much  reduced.  It  is  certain  that  the 
disease  has  been  contracted  by  an  individual  who  has  approached  a  patient  no 
nearer  than  three  feet,  and  it  is  well  established  that  the  disease  may  be  con- 
veyed by  third  persons  and  by  things.  The  contagion  is  given  off  from  the 
body  at  all  periods  of  the  disease,  and  also  for  some  time  after  death,  at  least 
up  to  decomposition,  but  not  so  long  as  to  account  for  the  cases  recorded  by 
Dr.  Franklin,  when  he  relates  that  ''several  medical  men  who  assisted  in 
London  at  the  dissection  of  a  mummy  died  of  a  malignant  fever,  which  it  was 
supposed  they  caught  from  the  dried  and  spiced  Egyptian." 

The  contagious  principle  or  cause  of  the  disease  has  not  yet  been  isolated, 
the  micro-organisms  discovered  being  only  those  of  pus.  AVe  have  to  remem- 
ber in  this  connection  that  the  same 
statements  were  made  for  a  long  time 
regarding  erysipelas  and  influenza,  whose 
micro-organisms  turned  out  to  be  quite 
different  or  to  have  different  properties 
from  those  of  pus.  To  speak  only  of 
the  latest  studies,  Weigert  found  in  the 
pustules  (see  Fig.  18)  the  streptococcus 
pyogenes,  which  Garr6  ascribed  to  mixed 
infection,  and  Guttmann  found  in  cult- 
ures from  pustules  the  staphylococcus 
pyogenes  aureus  and  the  staphylococcus 
albus.  V.  LoefF  claims  to  have  devel- 
oped in  sterilized  tubes  from  fresh  mat- 
ter amoeboid  proteids,  and  Pfeiffer  claims 
to  have  discovered  as  constantly  pres- 
ent in  the  exanthem  of  variola  a  parasite  of  the  species  protozoa,  which 
runs  its  whole  course  of  development  in  the  body  of  man  or  other  mammal. 
This  parasite  is  a  cell  of  round  or  oval  form,  33  fi  long  by  24  fx  broad,  with- 


FiG.  18. 


Capillary  of  Skin,  stuffed  with  Micrococci 
(Zuelzer). 


COURSE   OF   THE  DISEASE.  265 

out  cilia  or  meaus  of  attachment  or  opening,  and  enveloped  in  a  smooth  mem- 
brane.    Motion  is  present  only  in  its  early  amwha-like  stage,  and  reproduction 
occurs  in  the  budding  of"  spores  resembling  microcowi.     Pfeiffer  found  this 
])arasite  in  the  small-pox  of  man  as  well  as  in  genuine  cow-pox,  also  in  that 
of  the  hog,  cow,  horse,  pig,  and  goat.    Vaccine  matter,  especially  animal  matter, 
contains  fully-developed  protozoa  as  well  as  spores.     Judgment  is  reserved  as 
to  the  relation  to  the  disease  of  this  parasite,  which  is  studied  best  in  hanging 
drops.     Smaller  structures,  proteids  and  amoebse,  were  found  by  V.  der  Locff, 
in  great  number  and  much  variety  of  form,  in  matter  from  pustules  as  well  as 
from  fresh  animal  matter  examined  in  hanging  drops.     Colored  with  fuchsin, 
thev  may  be  studied  also  in  cover-glass  })reparations.    Garre  thinks  he  discovered 
the  cause  of  failure  of  detection  of  characteristic  micro-organisms  in  the  blood 
in  the  fact  that  investigations  had  been  made  at  too  late  a  period  of  the  disease. 
Bowen  states  that  he  discovered  nodules  of  reticular  structure,  with  subse- 
quent surface  pits  like  those  of  the  skin,  in  the  internal  organs — liver,  kidneys, 
lungs,  and  testes — but  without  a  trace  of  any  organisms.     Weigert  made  the 
same  observations,  and  Chiari  found  similar  forms  in  the  testes.     Berard  long 
ago  pointed  out  an  orchitis,  and  more  rarely  an  oophoritis,  as  complications  of 
small-pox.     Piotopopoff  examined  tiiis  lesion  microscopically,  and  discovered 
in  it  three  zones — a  central  total  necrosis,  a  middle  zone  with  small-cell  infil- 
tration, and  a  peripheric  zone  with  exudation.     He  hoped  to  be  able  to  isolate 
the  variolous  principle  in  these  studies.     He  examined   6  cases  in  boys  and 
made  cultures  in  glycerin  agar,  finding  in  all  6  cases  a  streptococcus  whose 
macroscojMc  and   microscopic  ajipearance  resembled  that  of  the  streptococcus 
pyogenes.     Bowen,  Garr6,  and  Hlava  reached  the  same  conclusion.     Inocula- 
tion of  this  streptococcus  in  animals  showed  in  the  case  of  rabbits  that    it 
]>ossessed  no  pathogenic  properties — an  additional  confirmation  of  the  view  of 
Koch  and  Schultze  that  our  present  methods  will  not  suffice  to  discover  the 
virus  of  variola. 

The  contagious  principle  or  cause  of  the  disease  is  disseminated,  as  stated, 
from  the  surface,  not  from  the  secretions,  throughout  its  whole  course,  includ- 
ing the  period  of  incubation,  also  for  some  time  after  death,  in  greatest  inten- 
sity with  the  maturation  of  the  vesicles,  so  that  infection  is  brought  about 
both  by  direct  and  indirect  contact,  and  the  contagion  may  remain  active, 
more  especially  in  clothing,  bedding,  etc.,  as  stated,  for  a  long  time. 

Proof  of  the  transference  of  the  disease  during  incubation  was  offered 
by  Schaper  in  the  ease  (jf  an  individual  who  had  ])articles  of  skin  engrafted 
upon  an  ulcer.  Tiie  ]>articles  were  taken  from  the  amputated  arm  of  a  man 
during  an  unsuspected  period  of  incubaticm  of  small-pox.  The  patient  who 
received  the  grafts  was  attacked  by  variola  <»n  the  sixth  day  after  the 
operation. 

Course  of  the  Disease. — The  period  of  iiicubntloii  varies  from  ten  to 
fourteen  days.  The  fact  that  the  disease  oecurs  at  such  intervals  iiiid 
announces  itself  with  such  marked  sym|)tt)ms  renders  observation  of  tliis 
period  easier   in  small-pox   than   in   nlinosf    miiv  other  disease.     It   is   usually 


266  SMALL-POX. 

easy  to  fix  the  exact  period  of  incubation  of  a  case  by  recall  of  the  exact 
moment  of  exposure.  To  be  of  value  in  fixing  this  period  the  exposure 
must  have  occurred,  of  course,  but  once  and  for  a  very  short  time.  Exact 
results  acquired  in  this  way  fix  the  period  of  incubation  for  ordinary 
exposure  at  from  ten  to  fourteen  days.  Thus,  Bjirensprung  saw  seven  cases 
all  infected  from  the  same  source  on  the  same  day.  In  every  one  of  them 
the  outbreak  occurred  between  the  thirteenth  and  fourteenth  day :  some 
of  them  had  been  vaccinated  and  some  had  not.  The  introduction  of  the 
poison  directly  into  the  blood  is  followed  by  symptoms  sooner,  as  the  period 
of  incubation  after  inoculation  is  but  six  to  seven  days.  There  is  during 
this  period,  as  a  rule,  no  disturbance  in  the  general  health.  The  individual  is 
unconscious  of  the  fact  that  he  has  become  the  victim  of  a  loathsome  disease. 
In  very  exceptional  cases  there  has  been  noticed  malaise,  a  sense  of  languor, 
and  sometimes  pharyngeal  catarrh.  But  Curschmann,  with  the  most  pains- 
taking investigations,  could  discover  these  signs  in  but  11  of  1000  cases — i.  e. 
less  than  1  per  cent.  The  character  of  the  symptoms  which  may  show  them- 
selves in  the  incubation  has  no  prognostic  value. 

Invasion  is  ushered  in  by  a  chill,  which  is,  as  a  rule,  violent,  with  rise  of 
temperature  to  103°-104°-  F.  on  the  first  day.  Prostration  may  be  pronounced 
from  the  start.  The  patient  is  put  to  bed,  or  if  on  his  feet  staggers  as  if 
drunk.  Anorexia,  vomiting,  jactitation,  insomnia,  and  severe  headache  set  in 
at  once.  Above  all  other  signs,  pain  in  the  loins  assumes  prominence.  It 
accompanies  the  fever  from  the  start,  and  subsides  only  with  its  fall  at  the 
apjiearance  of  the  eruption  on  the  third  day.  Persistent  pain  in  the  back 
(sacrum),  peculiar  in  its  intensity,  constitutes  the  most  characteristic  symjjtom 
of  this  stage ;  unfortunately,  it  is  present  in  but  little  more  than  one-half 
of  all  cases. 

The  initial  stage  of  invasion — i.  e.  the  period  from  the  chill  to  the  outbreak 
of  the  eruption — lasts,  as  stated,  three  days.  If  there  be  any  variation  from 
this  duration,  the  stage  is  rather  shorter  than  longer.  It  may  be  very  much 
longer  in  the  most  grave  form,  known  as  variola  hsemorrhagica  or  jiurjmra 
variolosa.  The  chill  which  announces  the  invasion  has  been  characterized  as 
violent.  In  this  regard  small-pox  associates  itself  with  malaria,  pneumonia, 
and  meningitis  (epidemic).  There  may  be,  however,  every  variety  of  inten- 
sity of  rigor,  or  the  single  severe  shock,  wdiich  is  marked  by  a  chill,  may  dis- 
tribute itself  over  a  longer  time  in  several  or  a  succession  of  chills  of  liarhter 
intensity.  The  temperature,  which  reaches,  as  a  rule,  103°-104°  F.  on  the 
evening  of  the  first  day,  may  continue  to  rise  to  reach  !106°  or  even  107°  F. 
by  the  time  of  the  appearance  of  the  eruption.  The  pulse,  which  runs  uji  to 
100-120,  in  women  130-140,  and  in  children  150-160,  usually  corresponds 
pretty  closely  with  the  temperature.  Respiration  increases  in  ratio  more  fre- 
quently than  the  pulse — to  such  degree  in  some  cases  as  to  constitute  dys])noea, 
probably  from  direct  action  upon  the  respiratory  centres.  Gastric  distress  is 
usually  a  prominent  feature  in  the  onset  of  small-pox.  Vomiting  may  be  so 
severe,  especially  in   grave  or  hseniorrhagic    forms,  as  to  constitute  a   very 


COURSE    OF    THE   DISEASE.  267 

serious  symptom.  Constipation  is  the  rule,  though  diarrhiea  is  not  iutVequeut 
in  childhood. 

All  these  symptoms  indicate  the  onset  of  a  irrave  infectious  disease.  There 
is,  however,  in  no  one  of  them  anything  especially  or  absolutely  characteristic. 
Stress  must  be  laid  now  upon  the  two  symptoms  which  early  assume  promi- 
nence, and  which  more  distinctly  bespeak  the  character  of  the  disease.  The 
most  frequent,  if  not  the  most  distinctive,  of  these  signs  is  hea<lache,  which  is, 
as  a  rule,  present  from  the  start.  It  sets  in  with  the  chill  or  occurs  in  a  few 
hours  in  the  course  of  the  subsequent  fever.  It  distinguishes  itself  not  only 
by  its  frequency,  but  by  its  severity.  It  persists  also  throughout  the  whole 
period  of  invasion,  to  become  milder  only  with  the  outbreak  of  the  eruption. 
The  physiognomy  of  the  patient,  the  flushed,  bloated  face,  bounding  vessels 
in  the  neck,  suffused  conjunctiva?,  expression  of  pain,  make  the  headache 
manifest. 

Pain  in  the  loins  is  common  to  all  acute  infections,  and  assumes  promi- 
nence in  correspondence  with  the  gravity  of  the  disease.  With  the  first 
records  of  small-pox  the  oldest  writers  laid  stress  upon  pain  in  the  back. 
Rhazes  certainly  appreciated  the  import  of  pain  in  the  back.  Thus  :  "  I  have 
found  the  peculiar  symptoms  of  the  small-pox  to  be  a  continued  fever,  jiain 
in  the  throat,  and  in  the  beginning  of  the  fever  pain  in  the  back."  Again  : 
"  If  a  person  has  a  pain  in  the  back  without  any  other  symptoms  of  the  dis- 
ease, ....  he  is  going  to  have  the  small-pox,  and,  in  short,  there  is  no  more 
characteristic  symptom  of  the  small-pox  than  pain  in  the  back  with  fever,  so 
that  when  you  see  this  pain  ....  you  may  be  sure  that  the  small-pox  is 
about  to  appear  rather  than  the  measles,  for  the  measles  are  not  attended  with 
pain  in  the  back."  Always  severe,  it  is  milder  in  the  lighter  cases,  as  in  vari- 
oloid, and  assumes  es|)ecial  intensity,  to  become  at  times  excessive  in  severity, 
in  the  worst,  heemorrhagic,  cases.  Excruciating  pain  in  the  back,  with  hix^mor- 
rhage  free^or  subcutaneous,  should  at  once  excite  suspicion  of  luemorrhagic 
small-pox.  It  usually  sets  in  early,  persists,  and  like  the  headache  remains 
up  to  the  period  of  eruption.  It  is,  however,  not  so  universally  present  as 
the  pain  in  the  head. 

Severe  symptoms  on  the  part  of  the  nervous  system  belong  to  bad  cases, 
and  occur  with  especial  frequency  in  childhood.  The  disease  is  sometimes 
announced  by  convulsions,  attacks  of  syncope,  and  occasionally  by  coma. 
Adults  as  well  as  children  may  actually  succumb  to  the  force  of  liie  initial 
shock,  thouirh  fulminant  forms  are  not  so  common   in  sniall-p(.x  as  in  scarlet 

fever. 

Evidence  of  infection  of  the  mucous  membranes  shows  itself  earlv.  Ther(> 
may  be  sometimes  seen  spots  upon  the  fauces,  especially  unoii  the  soil  |)alale. 
Coryza  with  ])hotophol>ia  and  epipliora  may  be  so  marked  as  t(»  siniiihile 
measles.     Bronchitis  is  not  so  frcfjucnt. 

Inasmuch  as  the  eruption  proper  does  not  appear  until  the  thiid  day, 
especial  value  is  attached  to  two  rashes  of  earlier  occurr.nee  in  certain  cases  or 
in  certain  epidemics.     One  is  petechial,  the  other  erythematous. 


268  ^SMALL-POX. 

Petechise  may  appear  on  the  second  day  in  the  form  of  a  fine  macular  or 
spotted  eruption  in  the  space  known  as  "  Simon's  triangle,"  whose  base  is  at 
the  umbilicus,  apex  at  the  knees.  It  may  occur  elsewhere,  especially  in  the 
space  under  the  axillae.  The  erythematous  eruption  has  its  favorite  spot  on 
the  sides  and  inner  surfaces  of  the  legs  from  the  ankles  up,  sometimes  in 
women  about  the  nipples.  This  eruption  indicates  a  mild  case  of  the  disease, 
whereas  petechiae  have  no  such  prognostic  value. 

Petechise  should  never  be  mistaken  for  the  true  hseraorrhagic  eruption, 
which  may  stamp  the  disease  from  the  start  or  occur  at  any  period  later. 
Both  these  eruptions  disappear,  as  a  rule,  in  twelve  to  twenty-four  hours. 
They  may  last  longer,  and  they  may,  especially  the  petechise,  leave  behind 
them  slight  brownish  discolorations. 

The  older  writers,  more  familiar  with  the  symptomatology  of  small-pox, 
admitted  the  possibility  of  termination  of  the  disease  at  this  stage.  These  are 
the  cases  of  lightest  possible  infection,  either  by  reason  of  natural  insuscepti- 
bility or  acquired  immunity,  as  by  inoculation  or  vaccination.  These  are 
the  cases  of  so-called  "  variola  sine  eruptione."  Absolute  proof  of  the  cha- 
racter of  the  infection  is  offered  in  the  universally  quoted  cases — one  is  enough 
for  proof — of  the  birth  of  a  foetus  in  any  stage  of  eruption  from  a  mother  who 
showed  signs  only  of  the  stage  of  invasion.  Additional  evidence  is  offered  in 
the  fatal  haemorrhagic  form  which  steps  in  to  shut  out  the  true  eruption. 
Subsequent  eruption  is  final  proof. 

The  distinctive  feature  of  small-pox  is  the  true  eruption.  The  symptoms 
hitherto  described,  the  severity  of  the  chill,  the  rapid  and  profound  prostration, 
the  vomiting,  the  pain  in  the  head  and  back,  should  excite  the  suspicion  of  the 
development  of  the  disease ;  and  these  symptoms  present  themselves  in  the 
nature  of  almost  absolute  evidence  in  the  presence  of  an  epidemic.  They  may, 
however,  any  or  all  of  them,  be  present  in  many  of  the  grave  acute  affections. 
Occurring  in  an  isolated  and  individual  case,  they  could  not  in  their  ensemble 
be  relied  upon  to  declare  the  diagnosis  of  small-pox.  The  initial  rashes  fur- 
nish more  convincing  proof.  This  fact  is  not  so  true  of  the  erythematous  as 
of  the  petechial  form.  Erythema  is  too  often  an  index  of  mere  reflex  disturb- 
ance. Petechial  eruption,  or  that  particular  petechial  eruption  which  early  in 
the  history  of  disease  shows  itself  in,  and  is  confined  to,  the  base  of  the  abdo- 
men and  the  inner  aspects  of  the  thighs  (Simon's  triangle),  is  surer  testimony. 
Diagnoses  have  been  made  upon  these  symptoms  alone,  and  cases  have  been 
recorded  where  the  disease,  as  stated,  cut  itself  short  at  this  j^eriod,  and  sub- 
sequent exemption  was  secured.  Petechise  elsewhere  furnish  no  necessary  evi- 
dence of  small-pox.  These  eruptions,  both  the  erythematous  and  the  petechial, 
are  often  entirely  absent.  They  occur  only  in  certain  individuals  and  in  certain 
epidemics.  When  present  they  are  often  overlooked.  The  nature  of  the  dis- 
ease is  therefore  only  finally  and  fully  declared  by  the  true  eruption  which 
shows  itself  on  the  third  day  of  the  disease. 

The  eruption  of  small-pox  is  peculiar.  It  differs  from  that  of  all  the  acute 
infections.     While  it  may  show  resemblance  at  first  to  the  eruption  of  other 


COURSE    OF    THE   DISEASE.  269 

diseases,  it  soon  assumes  changes  which  distintrnish  it.  The  eruption  of  small- 
pox runs  through  successive  phases  of  development.  It  is  at  first  jnipidar, 
then  vesicular,  then  pustular.  The  pustules  dry  to  form  crusts,  whicli  fall 
to  leave  most  characteristic  scars.  These  phases  of  development  mav  be  simu- 
lated to  some  extent  bv  varicella  or  bv  svphilis,  but  there  is  ahvavs  somethinor 
in  the  character,  conduct,  or  course  of  the  eruption  over  the  body  which  enables 
even  the  superficial  observer  to  separate  them  as  a  rule. 

In  its  very  first  appearance  the  eruption  is  purely  mac'idar — that  is,  not  ele- 
vated above  the  surface.  In  the  course  of  the  very  first  dav,  however,  so  intense 
is  the  inflammation,  the  macule  is  thickened  to  become  a  papule,  so  that,  as  a 
rule,  with  its  first  recognition  it  seems  lifted  above  the  general  surface.  It 
shows  itself  first  on  the  face  and  scalp,  where  it  is  unfortunately  alwavs  worst ; 
over  the  forehead  and  temples,  then  upon  the  sides  of  the  nose,  about  the  lips, 
over  the  chin,  and  s|)rca(]s  thence  downward  in  quite  regular  progression  over 
the  body.  Surfaces  rendered  hypersemic,  as  by  poultices  or  mustard  plastei-s, 
show  more  profuse  eruption.  The  hands  and  fingers  furnish  the  next  most 
favored  surfaces.  The  eruption  disappears  upon  pressnre,  yielding  to  palpation 
a  sense  of  hardness  as  of  shot  under  the  skin.  By  the  end  of  the  first  day, 
as  stated,  it  becomes  elevated,  and  by  the  third  day  is  distinctly  papular.  It 
is  always  discrete  at  first.  By  the  sixth  day  the  papules  contain  fluid  ;  tliey 
become  vesicles  and  protrude  like  half  peas.  These  vesicles  are  peculiar  in 
showing  later  a  central  depression  or  umbilicus,  which  is  most  marked  just 
before  the  vesicles  change  into  pustules.  The  depression  is  explained  in  tiiis 
way  :  The  vesicle  is  not  a  single  sac.  It  is  reticulated — i.  e.  many-celled — in 
structure,  so  that  puncture  evacuates  only  part  of  its  contents,  and  the  bands 
which  form  the  reticula  hold  down  the  surface  more  firmly  at  one  point, 
perhaps  the  site  of  a  hair-follicle,  sweat-gland,  or  firmer  strip  of  connective 
tissue.  Effusion  takes  place  between  the  upper  and  lower  layers  of  the  ej)idcr- 
mis  with  the  dissolution  of  these  bands.  In  three  days  more  the  umbilicus 
disappears,  the  vesicle  becomes  a  pustule,  which  is  full,  round,  and  large  ;  the 
half  becomes  a  whole  jiea.  With  the  coalescence  of  pustules  dividing  walls 
are  broken  down,  dissolved,  and  eroded.  The  eruption  becomes  confluent. 
The  contents  of  the  pustules  now  escape,  and,  becoming  inspissated  and  decom- 
posed, cause  the  pecidiarly  re|iulsive  appearance  and  odor  of  a  small-pox 
patient.  Desiccation  of  uidiberated  pus  to  form  crusts  begins  in  three  days 
more.  In  this  ))rocess  the  more  fluid  central  portions  evaporate  first,  to  repro- 
duce the  umbilicus.  The  crusts  fall  in  about  fifteen  days,  leaving  scars  or  pits 
the  result  of  necrosis  of  epidermic  cells.  Hyperremic  at  first,  the  scars  grow 
graduallv  lighter  in  color  and  more  contracted  in  circumference  than  the  sur- 
rounding skin,  until  finally  thoy  remain  as  disfiguring  white  spots  with  radiat- 
ing lines  for  years  in  childhood  or  fi)r  life  in  adults.  A  pectdiar  deformity 
ensues  at  times  about  the  ala;  of  the  nose,  with  notching  of  the  free  borders, 
and  distortions  as  from  extensive  biu-ns  are  ocensioually  seen  about  the 
face.  Every  possible  lesion  of  the  eve  up  to  cotn|)lete  blindness  and  destruc- 
tion of  the  globe  is  also  seen.     A  stroll  ni.uu  the  streets  in   {jre-vaecination,. 


270  SMALL-POX. 

clays,  when  these  accidents  were  to  be  observed  at  every  step,  would,  were  it 
possible,  do  more  to  dissipate  the  folly  of  the  opponents  of  vaccination  than 
mortnarv  statistics.  These  "  anti-vaccinationists  "  are  not  as  wise  as  the  pirates 
who  knew  that  dead  men  tell  no  tales. 

The  greater  or  less  abundance  of  the  eruption  distinguishes  certain  forms 
of  small-pox.  Where  the  pustules  stand  apart  the  attack  is  known  as  discrete, 
where  they  coalesce,  as  confluent.  There  is  in  no  case  coalescence  at  the  start. 
The  confluent  form  is  the  result  of  such  abundant  eruption  as  in  the  growth  of 
vesicles  to  more  than  cover  the  skin.  Vesicles  break  into  each  other  as  their 
surfaces  extend.  The  disease  distinguishes  itself  in  modified  form  by  show- 
ino-  the  eruption  always  discrete — /.  e.  less  abundant.  It  may  be  so  much  fur- 
ther modified  as  to  disturb  the  regular  course  of  other  features  of  the  disease. 
This  modification  is  observed  more  especially  in  cases  of  partial  immunity 
secured  by  previous  attack  or  vaccination,  and  this  much-modified  form  is 
known  as  varioloid. 

In  the  very  gravest  form  of  the  disease,  a  form  which  is  fatal  from  the 
start,  the  eruption  distinguishes  itself  by  its  absolute  absence.  The  peculiar 
eruption  of  small-pox  is  substituted  by  haemorrhage,  to  constitute  the  variety 
known  as  purpura  variolosa.  Quantitative  varieties  exist,  therefore,  in  modi- 
fied (varioloid),  discrete,  and  confluent  forms,  and  qualitative  in  hsemorrhagic 
forms. 

Returning  now  to  the  more  detailed  study  of  the  eruption,  it  is  observed 
that  it  appears  first  on  the  uppermost  part  of  the  body,  on  the  scalp,  about  the 
roots  of  the  hair,  on  the  forehead.  The  hair  conceals  it,  so  that,  as  a  rule,  the 
eruption  is  seen  first  on  the  forehead.  It  passes  down  thence  over  the  face  in 
regular  progression,  invades  next  the  neck  and  upper  extremities,  then  the 
chest  and  trunk,  and  lastly  the  lower  extremities.  Aitken  declares  that  it 
appears  in  these  different  parts  of  the  body  in  successive  crops,  the  first  upon 
the  face,  the  second  upon  the  neck  and  upper  extremities,  the  third  upon  the 
trunk  and  lower  extremities,  and  that  there  is  something  of  an  interval  in  the 
outbreak  of  these  eruptions.  A  distinctive  feature  of  the  disease  is  the  reg- 
ularity of  its  march,  so  that  while  it  is  pustular  u{)on  the  face  it  may  be  only 
vesicular  on  the  trunk,  and  at  the  end  of  the  papular  stage  on  the  lower 
extremities.  There  is  observed  also  regular  progress  in  the  stage  of  the  erup- 
tion, so  that  papules,  vesicles,  and  pustules  are  not  to  be  found  intermingled 
on  the  same  parts  of  the  body.  The  eruption,  of  whatever  form,  is  always 
less  marked  upon  the  body  than  the  face.  As  the  papules  develop  they 
become  more  and  more  conical,  to  finally  show  at  their  extreme  apices  a  clear 
opaline  fluid,  which  gradually  invades  the  substance  of  the  papule  to  convert 
it  into  a  vesicle.  The  reticulated  structure  of  the  vesicle  accounts  for  the  fact 
that  when  punctured  it  does  not  collapse,  but  allows  to  exude  from  its  interior 
only  a  small  quantity  of  its  contents.  The  vesicle  is,  as  stated,  many-celled. 
(See  Fig.  19.)  The  walls  of  these  cells  are  composed  in  part  of  sweat- 
glands  or  hair-follicles — structures  which  resist  the  erosive  action  of  pus 
or  of  the  poison  of  the  disease,  so  that,  while  the  vesicle  expands  in  every 


COURSE    OF    THE   DISEASE. 


271 


direction,  it  is  held  down  bv  these  tirnicr  tissues.  This  fact  accounts,  as 
stated,  for  the  central  or  eccentric  depression  which  is  regarded  as  such  a 
cliaracteristic  feature  of  small-pox.  It  must  be  said,  however,  that  many 
vesicles  and  pustules  which  show  no  umbilication  or  depression  may  always 
be  encountered.     It   must  be  further  admitted  tiiat  this  same  central  depres- 


Section  of  Variolous  Lesion  of  the  Skin :  a,  outer  layer  of  epidermis;  ft,  midille  layer;  c,  cylindrical  cells 
of  the  rete  Malpighii  resting  immediately  upon  the  papilUe ;  d,  reticulated  cavity  of  the  pock,  con- 
taining pus-corpuscles,  with  the  epithelial  framework  ;  e,  purulent  infiltration  of  the  middle  layer  of 
the  epidermis  (Curschmann). 


sion  is  also  occasionally,  but  by  no  means  so  commoidy,  .seen  in  the  vesi- 
cles of  varicella  and  syphilis.  So  soon  as  the  vesicle  has  become  thor- 
oughly distended  it  loses  its  clarity,  to  become  more  and  more  turbid  and 
opaque — that  is,  the  number  of  pus-corpuscles  increases.  The  inflamma- 
tion has  become  now  ,so  extensive  as  to  have  affected  subjacent  structures, 
so  that  the  base  of  the  ])ustulc  becomes  dark  and  the  pustule  itself  seems 
surrounded  by  a  halo.  The  whole  skin  is  now  infiltrated  and  thickened,  and 
where  the  eruption  is  abundant,  as  upon  the  face,  the  eyes  and  ears  are  swollen 
to  closure,  the  face  bloated  to  distortion.  The  distension  may  be  so  great, 
esjiecially  in  unyielding  structures,  as  to  give  ri.se  to  extreme  pain.  Pain  is 
felt  more  especially  in  the  fingers,  where  tlie  eruption  is  always  so  abundant, 
even  in  pronounced  di.screte  forms  of  the  disease,  as  to  show  .some  degree  of 
confluence.  The  pain  of  this  distension  about  the  fingers  may  be  so  great  as 
to  overshadow  all  other  subjective  sensations  :iii(l  reipiire  es|)ecial  treatment  in 
its  relief.  One  may  only  realize  the  severity  ol"  the  pain  in  tin-  fingers  by 
recalling  the  amount  of  suffering  which  is  occasioncil  by  :i  single  |»ar(»nychia. 
In  small-j)ox  there  ai'e  paronychia'  n|)()n  every  finger.  'I'lie  old  wi'iters  speak 
of  the  cedemato-phlegmonous  inflammation  of"  the  e.\(  icniities.     A  few  pustules 


272 


SMALL-POX. 


in  the  eye  may  destroy  the  sight.  Van  Swieten  records  a  case  where  a  single 
pustule  on  the  prepuce  produced  a  painful  phimosis  and  dysuria. 

Curschmann  claims  that  the  more  abundant  eruption  observed  under  heat 
or  moisture,  under  poultices,  plasters,  etc.,  shows  itself  only  when  these  a]ij)li- 
catious  are  made  before  infection  or  in  the  stage  of  incubation.  When  he 
produced  hyperemia  later,  as  in  the  initial  stage,  with  mustard  plasters, 
iodine,  etc.,  the  eruption  was  not  thicker  here  than  elsewhere.  In  one  case  in 
his  experience  an  individual  presented  himself  with  long  lines  of  eczema,  the 
result  of  numerous  scratchings  of  the  skin  for  relief  of  the  irritation  of  pediculi. 
The  eruption  when  it  occurred  showed  itself  in  these  lines  and  seemed  studded 
with  pustules  like  strings  of  pearls. 

The  eruption  of  small-pox  does  not  confine  itself  to  the  outside  skin,  but 
appears  also  on  the  inside  skin,  the  mucous  membrane  of  the  mouth,  pharynx, 
and  sometimes  deeper  structures.  It  may  be  nearly  always  discovered  in  the 
fauces,  over  the  palate  and  tonsils,  and  sometimes  on  the  inner  surfaces  of  the 
lips  and  cheeks.  Occasionally  it  invades  the  larynx,  to  alter  or  abolish  the 
voice.  It  may  show  also  deeper  lesion  than  hypersemia  and  swelling  of  the 
mucous  membrane.  Ulcers  may  form  in  the  larynx,  with  affection  of  the 
cartilage,  perichondritis,  and  oedema  of  the  glottis.  In  a  bad  case  the  tongue, 
which  seldom  shows  any  sign  of  eruption,  is  swollen  to  such  extent  as  to  pro- 
trude from  the  mouth,  and  in  confluent  cases  salivation  may  be  profuse.  The 
aifection  may  also  extend  from  the  throat  to  the  nose,  which  it  may  block  from 
behind,  and  subsequently  involve  the  Eustachian  tubes  and  middle  ear.  Mu- 
cosae of  other  parts  of  the  body  are  rarely  invaded. 


Fig.  20. 

FaK* 

104.    0 
102     2 

too  * 

9H    6 

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, —     -■   ~                                  —           ^-.--       _-^"     __-  ^     i"±._l: 

Temperature-ohart  of  Case  of  Variola  (Wunderlich). 


The  course  of  the  temperature  in  variola  is  characteristic.  (See  Fig.  20.) 
The  fever  reaches  its  height,  as  stated,  with  the  period  of  eruption.  As  soon  as 
the  eruption  has  covered  the  body  the  temperature  begins  to  subside,  and  falls 
often  nearly  to  the  normal  grade  within  thirty-six  hours.  With  the  subsidence 
of  the  temperature  the  pain  in  the  back,  the  nausea,  and  vomiting  disappear, 
and  the  patient  seems  on  the  road  to  recovery.  As  soon,  however,  as  the  vesi- 
cles become  converted  into  pustules,  about  the  sixth  or  ninth  day  of  the  disease, 
the  fever  is  renewed,  sometimes  with  shivering  fits,  always  with  a  ri.se  of  tem- 
perature to  102°  or  103°  F.,  but  rarely  to  the  elevations  reached  during  the 
stage  of  invasion.     This  is  the  .secondary  fever,  the  fever  of  suppuration,  caused 


COURSE   OF   THE  DISEASE.  273 

entirely  by  the  micro-organisms  of  pns.  Strictly  speaking,  it  does  not  belong 
to  the  small-pox  process.  It  is  only  a  secondary  effect,  but  is  none  the  less  cha- 
racteristic of  the  course  of  the  disease.  AVith  the  stae-e  of  desiccation  the  fever 
again  gradually  subsides,  to  terminate  by  lysis  in  the  course  of  the  subsequent 
week.  This  subsidence,  however,  may  be  at  any  time  interrupted  and  the  fever 
aggravated  by  complications. 

In  confluent  small-pox  the  eruption  is  more  abundant  from  the  start.  It 
shows  itself,  instead  of  in  distinct  maculae  or  papules,  as  a  more  profuse  red- 
ness from  coalescence.  Sometimes  the  sense  of  hardness  or  unevenness  of  the 
surface  may  not  be  recognized  on  account  of  the  more  uniform  elevation  of  the 
whole  surface.  The  individual  papules  are  always  smaller  than  in  the  discrete 
form,  but  they  are  much  more  abundant.  The  stage  of  vesiculation  is  repre- 
sented by  an  accumulation  of  a  more  or  less  milky  fluid  over  flat  surfaces, 
often  in  irregular  or  zigzag  shapes.  The  swelling  is  greater,  as  is  also  the 
corresponding  deformity  at  the  period  of  suppuration.  The  eyes  and  the  ears 
are  swollen,  the  face  is  enormously  bloated.  The  scalp  is  lifted  from  the  head, 
and  the  face  has  the  appearance  as  if  covered  with  a  mask  or  heavily  coated 
with  coarse  sand  [pergamence  speciem  visu  horrendam  (cutis  faciei)  exhibet) 
(Morton).  With  the  rupture  of  this  parchment-like  coat  masses  of  decom- 
posing fluid  ooze  out  to  stream  down  over  the  face  and  make  of  the  patient  an 
object  so  loathsome  as  to  be  repulsive  even  to  intimate  relatives. 

Chief  among  the  varieties  of  small-pox  are  the  abortive  and  haemorrhagic 
forms.  The  abortive  is  that  varietv  in  which  the  course  of  the  disease  is 
altered  from  the  start.  The  period  of  incubation  is  sometimes  shortened,  the 
invasion  may  be  brief,  the  eruption  changed  in  various  ways,  the  duration  cut 
short.  This  form  is  best  described  under  the  rather  unfortunate  denomination 
of  "  varioloid." 

Haemorrhage  may  occur  in  the  course  of  small-pox  in  no  less  than  four  dis- 
tinct varieties.  Blood  is  not  unfrequently  effused  in  the  vesicles  or  pustules 
of  patients  who  do  not  remain  recumbent,  mIio  leave  the  bed  and  get  up  too 
soon  in  the  period  of  convalescence.  In  these  cases  the  h.iemorrhage  is  con- 
fined almost  exclusively  to  the  lower  extremities,  and  shows  itself  as  petechiie 
or  purpura,  not  unlike  the  common  form  of  this  aflection.  Such  hremorrhage 
is  purely  local,  due  to  escape  of  blood  through  paretic  vessels.  It  s|)eedily 
subsides  by  absorption  with  rest  in  bed  ;   it  has  no  prognostic  gravity. 

Reference  has  already  been  made  to  that  petechial  cruj)tion  which  occurs 
as  an  initial  rash  on  the  lower  surfaces  of  the  abdomen  and  inner  aspect  of  the 
thighs.  This  eruption  has  also  a  haemorrhagic  foiuidalion.  It  is  of  diagnos- 
tic value,  but,  as  stated,  has  no  ])rognostic  significance. 

Aside  from  these  eruptions,  blood  may  be  poured  out  into  (he  Inic  erup- 
tions of  small-pox  at  any  part  of  the  course  of  the  disease.  This  accident 
occurs  most  frerpientlv  in  cases  debilitated  by  j)revious  disease  oi-  bad  sur- 
roundings, but  sometimes,  fortiniately  exceptionally.  \\\u\ry  lotnlly  uiiaeeoinit- 
able  circumstances.  The  blood  is  effused  ;i(  limes  iiilo  thi'  papules,  more  fre- 
quently into  vesicles,  at  the  period  of  lull   niatnration — /.  c.  at   the  height  of 

Vol..  I.— 18 


274  SMALL-POX. 

the  disease.  The  clear  serum  becomes  turbid,  sero-sanguinolent,  and  finally 
the  vesicle  is  filled  with  blood.  Sheets  of  blood,  diifuse  and  black,  fill  the 
interior  of  confluent  vesicles  and  pustules,  and  blood  appears  under  the  skin 
as  livid  patches,  vibices,  and  ecchymoses  in  various  parts  of  the  body,  to  con- 
stitute what  is  called  hsemorrhagic  small-pox,  black  small-pox,  "  variola 
nigra."  With  this  effusion  of  blood  there  is  a  corresponding  collapse.  Free 
haemorrhages — metrorrhagia,  hsematuria,  enterorrhagia,  least  frequently  hsema- 
temesis — may  occur  also  from  the  various  mucous  surfaces,  under  which  the 
patient  rapidly  succumbs.  Should  he  survive  the  prostration  caused  by  the 
l)£emorrhage  itself,  he  may  have  to  face  other  and  worse  dangers.  Diphther- 
itic deposits  form  in  the  pharynx,  a  scorbutic  condition  of  the  gums  develops, 
or  nephritis  ensues  and  the  patient  may  perish  from  ursemia.  Recovery  from 
this  condition  is  rare ;  convalescence  is  slow  and  tedious. 

Last  among  the  hsemorrhagic  eruptions  remains  to  be  described  that  par- 
ticular variety  in  which  the  haemorrhage  assumes  prominence  over  all  other 
signs.  This  variety  presents  such  distinctive  features,  so  different  from  all 
other  forms  of  small-pox,  as  to  have  led  competent  observers  to  consider  it  a 
special  malady.  The  fact  that  the  disease,  in  any  of  its  forms,  may  be  com- 
municated from  this  form,  and  that  the  body  remains  infectious  also  after 
death,  establishes  its  true  nature.  That  this  hsemorrhagic  form  may  be  dis- 
tinguished from  those  just  described,  esjiecially  from  the  variola  hsemorrhagica 
pustulosa,  it  has  been  given  the  se})arate  name  of  "purpura  variolosa" — a 
term  which  fixes  in  the  foreground  the  hsemorrhagic  character  which  literally 
dominates  the  disease.  In  this  variety  of  small-pox  the  initial  rash  and  the 
true  eruption  are  alike  wanting.  Although  this  is  the  fulminant  form  of 
small-pox,  it  does  not  necessarily  commence  with  violent  signs.  It  attacks, 
by  preference,  the  young,  healthy,  and  strong,  but  does  not  spare  the  weak  and 
debilitated.  Drinkers  and  pregnant  and  parturient  women  are  among  its 
preferred  victims. 

The  disease  begins  in  the  ordinary  way — with  chill,  vomiting,  and  rapid 
prostration.  The  stage  of  invasion  (if  it  differ  in  any  way  from  the  ordinary 
oases  of  small-pox)  is  distinguished  by  the  severity  of  pain  in  the  back. 
In  the  experience  of  the  author  patients  have  complained  of  excruciating  pain 
in  the  back  when  there  was  no  other  symptom,  not  even  fever.  Another  dis- 
tinctive feature  is  the  rapidity  of  appearance  of  hsemorrhage.  Should  the  dis- 
ease occur  during  menstruation,  metrorrhagia  ensues,  and  the  nature  of  the 
disease  may  be  thus  overlooked,  as  the  jiain  and  the  hfemorrhage  may  be  both 
connected  with  menstruation.  Hsemorrhage  now  shows  itself  under  the  skin — 
first  u})on  the  trunk,  later  upon  the  extremities,  but  never  upon  the  face.  The 
surface  assumes  a  blood-red  hue,  like  that  of  scarlet  fever,  and  in  this  redness 
points  and  patches  of  blood  appear.  The  eruption  is  usually  petechial  upon 
the  extremities  and  confluent  as  irregular  ecchymotic  patches  on  the  chest  and 
trunk.  The  face  is  swollen,  the  eyes  suffused  and  sunken  and  surrounded 
with  black  rings.  The  tongue  is  thick  and  heavily  coated.  The  breath  is 
exceedingly  foetid.     There  may  be  elevation  of  temperature ;  sometimes  there 


COURSE    OF   THE  DISEASE.  275 

is  no  fever,  and  often  the  temperature  is  subnormal.  Tiic  tendency  is  steadily 
downward,  and  death  occurs  by  the  end  of  the  first  week.  Fortunately,  this 
form  occurs  in  but  5  per  cent,  of  cases. 

A  peculiar  snbvariety.or  disposition  of  eruption  is  that  described  by  Mar- 
son  as  "corymbose."  In  these  cases  the  eruption  shows  itself  in  patches  or 
clusters  the  size  of  the  hand,  as  thickly  set  as  possible,  while  the  surrounding 
skin  remains  often  entirely  free.  The  patches  are  often  symmetrically  distrib- 
uted upon  the  extremities.  The  variety  is  very  rare,  but,  contrary  to  what 
might  be  expected,  is  very  dangerous.  Marson  found  that  the  appearance  of 
but  a  single  cluster  gave  gravity  to  the  attack,  and  rendered  it  much  more 
liable  to  complications  and  greatly  protracted  convalescence.  The  mortality 
was  over  40  per  cent.  Other  singnlarities  are  verrucose,  pemphigose,  or  mil- 
iary eruptions.     They  are,  however,  more  commonly  met  with  in  varioloid. 

Varioloid  is  a  misnomer,  for  the  affection  is  not  like  variola  ;  it  is  variola 
itself.  Varioloid  does  not  stand  in  the  same  relation  to  variola  as  typhoid  to 
typhus  fever;  varioloid  is  variola  in  modified  form — is,  in  fact,  the  lightest 
form  of  small-pox.  The  disease  occurs  in  this  form  on  account  of  natural 
insusceptibility,  on  account  of  ])revious  attack,  formerly  on  account  of  inocu- 
lation ;  but  the  great  majority  of  cases  seen  in  our  day  are  due  to  incomplete 
])rotection  from  vaccination.  The  immunity  secured  by  vaccination  has  run 
(»nt,  and  the  severity  of  the  attack  Avill,  to  a  certain  extent,  depend  npon  the 
remaining  degree  of  protection.  A  case  of  unmodified  variola  in  our  day  is 
a  rarity  ;  that  modified  or  jnitigated  variola  known  as  varioloid  is  still  fre- 
quently seen.  A  knowledge  of  the  nature  of  varioloid  and  its  differences 
from  other  simulating  affections  is  necessary,  that  the  disease  be  recognized 
at  once  in  protection  of  others.  From  what  has  been  stated  it  is  needless  to 
add  that  varioloid,  mild  as  it  may  be  in  itself,  may  transmit  true  variola  in 
anv,  even  its  most  fulminant,  form.  Most  of  the  cases  encountered  in  our 
day  are  so  mild  that  the  question  of  diagnosis  concerns  differentiation  of 
varioloid  from   varicella  as  much  as  the  recognition  of  variola  itself 

As  already  stated,  small-pox  is  a  very  uniform  disease.  In  modified  form, 
however,  it  presents  many  irregularities.  Varioloid  distinguishes  itself  by 
abnormalities  in  every  stage  of  the  disease.  As  most  of  the  cases  are  due  to 
incomplete  protection  by  vaccination,  the  various  irregularities  are  mentioned 
by  Morrow  when  he  says  that  "  vaccination  denaturalizes  small-pox,  deranges 
the  original  order  of  the  disease,  and  effaces  its  most  distinctive  features." 

It  is  generally  assumed  that  the  modification  of  .symptoms  is  apparent  in 
the  initial  stage  of  the  disease.  This  view,  however,  is  by  no  means  correct. 
The  disease  begins  with  its  nsual  train  of  symj)toms,  and  a-  a  rule  with  its 
orii'inal  violence.  The  diflfcrenee  concerns  duration  rather  than  degree.  The 
initial  stage  is  often  cut  short  a  day  or  two,  so  that  the  eruption  may  ai)i)ear  by 
the  end  of  the  first  or  second  day.  'i1ie  various  initial  eruptions  occur  also 
in  varioloid — the  petechial  as  an  exccjition,  th<'  ervthematous  as  a  rule.  It  is  a 
common  observation  that  a  prouotuiced  erytlieuiatous  eruption  or  scarlatiui- 
form  rash  betokens  varioloid  rather  than  variola.     Curschniann  declares   that 


276  SMALL-POX. 

we  may  predict,  in  spite  of  the  severe  depression  of  the  general  system,  that 
the  form  of  the  disease,  if  erythematous,  will  be  mild,  while  petechise  will 
nearly  always  be  followed  by  variola  vera,  which  is  not  infrequently  conflu- 
ent. For  what  comfort  it  may  bring,  the  author  may  state  that  the  three  cases 
of  petechial  eruptions  in  Simon's  triangle  which  have  occurred  iu  his  expe- 
rience have  preceded,  without  exception,  mild,  abortive  attacks  of  the  disease. 

With  regard  to  the  real  eruption,  varioloid  presents  the  greatest  variations. 
It  may  begin  on  the  scalp,  forehead,  and  temples,  as  in  an  ordinary  case,  and 
progress  in  regular  or  irregular  course.  It  may,  on  the  other  hand,  show 
itself  first  on  the  neck  and  chest  or  elsewhere  over  the  trunk,  to  appear  later 
on  the  extremities  or  face.  As  a  rule  it  is  much  less  abundant,  so  that  it  is 
nearly  always  discrete.  There  are,  however,  exceptions  to  this  rule,  and 
marked  cases  may  show  isolated  patches  of  confluence  on  the  face  and  hands. 
On  its  first  appearance  the  eruption  differs  in  no  way  from  that  of  the  more 
pronounced  form  of  the  disease.  It  comes  out  in  spots,  which  are  elevated 
into  papules  in  the  course  of  the  first  day.  The  papules  slowly  show  fluid  at 
their  accuminated  apices,  and  become  thus  entirely  converted  into  vesicles  as 
before.  Here,  now,  the  change  is  usually  observed  :  the  eruption  usually 
stops  at  this  stage,  and  the  vesicles,  which  may  have  become  umbilicated, 
begin  to  dry  up  and  disappear.  They  may  fill  out  as  in  the  course  of  severer 
forms ;  their  contents  may  become  turbid  and  opaque,  and  the  vesicle  may  be 
transformed  into  a  pustule,  but  it  is  plain  to  see  that  the  force  of  the  disease 
is  spent.  Certain  pustules  may  rupture,  but  the  process  is  limited,  and  the 
secondary  fever  of  suppuration  is  reduced  or  is  entirely  absent.  In  conse- 
quence of  the  fact  that  pustulation  does  occur  in  places  with  erosion  and 
destruction  of  tissue,  pits  may  be  left,  but  they  are  few  and  far  between  as 
compared  with  the  lesions  of  ordinary  small-pox. 

The  disturbance  of  the  general  progress  of  the  disease  is  marked  also  by 
irregularity.  It  is  more  common  to  find  pustules  and  vesicles  or  vesicles  and 
papules  in  a  closer  proximity  in  varioloid  than  in  variola.  Moreover,  the 
eruption  does  not  last  so  long.  Desiccation  begins  on  the  fifth  or  seventh  day, 
and  most  of  the  papules  dry  up  into  crusts  without  rupture.  These  crusts,  as 
a  rule,  leave  only  pigmented  traces  without  scars.  There  is  often  also  dispro- 
portion between  the  severity  of  the  fever  and  the  eruption.  There  may  be 
high  fever  in  the  presence  of  but  ten  or  twenty  vesicles  or  pustules  over  the 
body,  or,  per  contra,  the  eruption  may  be  almost,  or  in  places  entirely,  con- 
fluent, with  but  little  elevation  of  temperature.  It  is  plain  to  see  that  vac- 
cination has  at  every  point  put  a  muzzle  upon  the  disease. 

The  various  transfi)rmations  of  vesicles  and  papules  which  may  occur  dur- 
ing the  process  of  modification  or  abortion  may  convert  vesicles  or  pustules 
into  warty  masses  or  bullse,  or  ruptured  vesicles  may  fill  with  air  to  constitute 
varieties  known  as  variola  verrucosa,  pemphigosa,  miliaris,  ventosa,  or  cellulosa, 
etc.  So  of  the  various  affections  of  the  mucous  membrane.  While  they  may 
be  present,  or  in  individual  cases  more  or  less  pronounced,  in  initial  stages 
they  rarely  assume  prominence  or  give  rise  to  serious  complications. 


COMPLICA  TIOXS.—DIA  GNOSIS.  277 

Complications  which  occur  in  the  course  of  small-pox  do  not  differ  much 
from  those  of  equally  grave  acute  infections.  Sufficient  mention  has  already 
been  made  of  the  lighter  affections  of  the  pharynx  and  larynx.  It  remains  to 
be  said  that  gangrenous  processes,  oedema  of  the  glottis,  and  perichondritis 
occur  in  exceptional  cases.  Stenosis  from  either  of  these  causes  may  necessi- 
tate intubation  or  tracheotomy. 

Bronchitis  belongs  to  variola  as  to  most  of  the  exanthemata.  It  is  very 
liable  to  extend  in  childhood,  to  infect  the  finer  bronchial  tubes,  and  to  result 
in  broncho-pneumonia.  Pleurisy  is  by  no  means  so  common,  but  is  by  no 
means  rare.  Pericarditis,  endocarditis,  endometritis,  meningitis,  are  not  uncom- 
mon complications  in  grave  cases.  Affections  of  the  joints,  arthritis,  pyaemia, 
septicaemia  are  much  more  frequent. 

Small-pox  occasionally  affects  the  eye.  Conjunctivitis,  keratitis,  affections 
of  the  lids,  are  the  most  common  lesions.  Disease  of  the  choroid  and  retina 
occurs  in  exceptional  cases.  Panophthalmitis,  with  destruction  of  the  globe, 
was  not  uncommon  in  ancient  times.  Ocular  complications  in  our  day  are 
neither  frequent  nor  severe.  In  all  his  remarkable  experience  Hebra  saw 
them  in  only  1   per  cent,  of  5000  cases  of  small-pox. 

By  extension  of  the  inflammation  of  the  fauces  and  pharynx  the  middle 
ear  may  be  attacked,  to  result  in  otitis  or  otorrhoea,  with  subsequent  ankylosis 
of  bones  and  deafness.  Phlegmonous  inflammations,  gangrene  of  the  skin, 
and  furunculosis  occur  frequently  in  confluent  cases ;  and  local  and  diff'uscd 
inflammation  of  the  brain  and  cord,  paralysis,  and  bed-sores  may  nearly  com- 
plete the  possible  complications. 

Diagnosis. — The  diagnosis  of  the  disease  rests  upon  the  following  points : 
the  possible  existence  of  other  cases,  the  history  of  sufficiently  recent  protec- 
tion by  vaccination.  The  mere  existence  of  a  scar  is  no  evidence  of  protec- 
tion. The  worst  case  of  purpura  variola  encountered  in  the  experience  of  the 
author  had  three  well-marked  cicatrices  upon  the  arm  as  evidence  of  previous 
vaccination.  Then  it  is  observed  that  the  illness  sets  in  suddenly,  and  is 
usually  severe  from  the  start.  Strong  men  stagger  as  if  drunk.  The  tem- 
perature rises  rapidly.  Pain  in  the  back  is  peculiar  in  its  intensity  ;  initial 
eruptions  may  be  characteristic.  The  true  eruption  appears  upon  the  third 
day  after  the  initial  chill.  It  is  maculated,  not  punctate  like  that  of  scarla- 
tina, but  darker  than  the  scarlet  of  scarlatina  and  lighter  than  the  dusky  hue 
of  measles.  It  is  seen  first  upon  the  scalp  and  upper  part  of  the  face,  spread- 
ing downward  regularly  and  rapidly  ;  it  does  not  sjiare  the  nose  or  region  of 
the  mouth.  It  yields  a  peculiar  feeling  of  hardness  as  of  shot  under  the  skin. 
Elevation  into  papules  occurs  during  the  first  day.  The  diagnosis  becomes 
nearly  certain  when  the  pai)ides  by  the  third  day  change  into  vesicles,  some 
of  which  subsequently  bccotnc  umbilicated. 

Small-pox  is  one  of  the  most  grave  of  the  acute  infi-ctions  which  survives 
from  the  pre-sanitary  period  of  civilization.  We  see  it,  fi)r  the  most  i)art,  as 
a  mere  relic  or  rudiment  of  its  former  self.  There  is  lacking  with  us  that  ele- 
ment of  tiHiltitiidinous  infection   which  gives  voliiiiic    and    virulence   to    the 


278  SMALL-POX. 

disease.  Nevertheless,  even  in  its  modified  form,  it  preserves  its  character  as 
a  grave  infection,  and  it  may  hence  be  confounded  with  any  of  the  infections 
of  equal  gravity,  especially  any  of  those  that  are  attended  with  an  eruption. 

Disregarding  the  eruption  for  the  present,  because  not  present  at  the  start, 
mistakes  have  thus  arisen  in  connection  with  meningitis,  pneumonia,  and 
typhus  fever.  Meningitis,  especially  the  cerebro-spinal  form,  pneumonia, 
and  typhus  fever  begin,  like  small-pox,  in  the  midst  of  health,  with  violent 
chill,  rise  of  temperature,  and  rapid  prostration.  Gastric  symptoms,  vomiting 
or  nervous  shock,  especially  in  children,  and  convulsions,  may  announce  the 
onset  of  any  of  these  infections.  In  the  absence  of  an  epidemic  or  the  history 
of  exposure,  in  the  absence  also  of  adequate  protection  by  vaccination,  the 
diagnosis  must  sometimes  be  held  in  abeyance  for  twenty-four  or  forty-eight 
hours  until  distinctive  signs  of  one  or  the  other  of  these  diseases  are  manifest. 
Meningitis  distinguishes  itself  by  hypersesthesia,  opisthotonos,  and  herpes,  as 
well  as  by  its  irregular  temperature  curve.  Pneumonia  is  early  characterized 
by  pain  in  the  side,  cough  with  glutinous  and  rusty  sputum,  and  increase  of 
respiration  out  of  proportion  to  the  pulse.  The  diseases  which  are,  however, 
most  frequently  confounded  with  small-pox  are  those  which  are  attended  with 
an  eruption,  and  chief  among  these  is  typhus  fever.  Typhus  fever  has,  how- 
ever, a  history  of  importation  which  may  be  traced  or  prevalence  which  may 
be  known.  It  begins  often,  like  small-pox,  suddenly,  with  a  severe  chill  in 
the  midst  of  health,  and  shows  an  eruption  on  the  third  day.  The  eruption 
of  typhus,  however,  appears  first  upon  the  body,  chest,  and  abdomen  in  the 
form  of  maculas  which  soon  become  petechial.  The  eruption  of  small-pox 
appears  first  upon  the  scalp  and  forehead,  and  progresses  over  the  face  before 
it  appears  upon  the  body.  It  shows  itself  in  the  form  of  maculae,  which 
soon  become  papular,  vesicular,  etc.  ^The  petechiae  which  may  occur  in  small- 
pox occur  on  the  legs  or  thighs  or  in  the  course  of  a  lisemorrhagic  form. 
Vesicles,  especially  umbilicated  vesicles,  are  never  seen  in  typhus  fever. 
There  is  also  characteristic  difference  in  temperature,  whi(;h  subsides  with 
the  appearance  of  the  eruption  in  small-pox,  but  persists  unaffected  for  sev- 
eral days  or  as  long  as  a  week  in  typhus  fever. 

Confusion  with  typhoid  fever  is  less  pardonable.  Typhoid  fever  begins 
insidiously,  requiring  the  time  of  a  week  to  reach  the  temperature  attained 
by  small-pox  in  a  day  or  two.  The  cloud  about  the  brain  which  belongs  both 
to  typhoid  and  typhus  fever  from  the  start  is  not  present  in  small-})ox  until  the 
last  stages  of  the  disease.  Typhoid  fever  shows  abdominal  symptoms,  roseola 
on  the  seventh  to  tenth  day,  meteorism,  gurgling,  diarrhoea,  etc.,  absent  in 
small-pox. 

A  light  case  of  small-pox  may  be  regarded  as  measles,  and  a  bad  case  of 
measles  as  small-pox.  Consequently,  the  separation  of  small-pox  from  measles 
is  the  most  frequent  problem  submitted  to  the  practitioner.  The  future  of  the 
case,  the  safety  of  the  community,  the  reputation  of  the  physician,  depend  upon 
the  proper  solution  of  this  problem.  Here,  too,  help  may  be  had  by  a  know- 
ledge of  the  history  of  the  case  as  to  the  existence  or  absence  of  an  attack  of 


DIAG.XOSIS.  279 

measles  or  sniall-pox,  the  period  of  the  ki.->t  successful  vaccination,  the  prev- 
alence of  either  disease  in  the  couimuuity.     As  for  measles,  it  is  always  present 
in  cities,  and,  thanks  to  the  popular  iear  of  suiall-pox,  knowledge  of  its  exist- 
ence is  early  promulgated  by  the  health  authorities.     Nevertheless,  sporadic 
cases  steal  in  at  times  unannounced.     In  the  experience  of  the  author  with  the 
management  of  a  large  dispensary  practice  small-pox  was  twice  introduced  into 
Cincinnati   by  pei'ipatetic  philosophers  commonly  called   "tramps."      These 
cases  formed  centres  of  infection.     Knowledge  of  the  period  of  exposure — /.  e. 
the  period  of  incubation — is  of  little  value.     The  stage  of  invasion  is  much 
milder  in  measles  than  in  even  modified  forms  of  small-pox,  for,  as  has  been 
stated,  varioloid  may  be  announced  with  symptoms  as  severe  as  those  which  dis- 
tinguish the  onset  of  variola  vera.    The  chill  is  less  severe,  the  fever  is  less  high, 
the  prostration  is  less  profound,  in  measles  as  a  rule.    There  are,  of  course,  excep- 
tions on  both  sides.     The  eruption  ap})ears  on  the  third  day  of  small-pox,  on 
the  fourth  day  of  measles.     The  maculse  of  measles  are  bigger  than  those 
of  small-pox.     They  appear  also  upon  the  back  almost  at  the  same  time  as 
upon  the  face,  whereas  the  eruption  of  small-pox  much  more  uniformly  apj)ears 
upon  the  face,  and  reaches  the  back  only  later  in  its  advance  over  the  body. 
The  maculse  of  measles  are  softer  than  those  of  small-pox.     Rhazes  said  nearly 
a  thousand  years  ago :  "  The  diiference  between  the  two  he  found  to  be  that 
measles  are  red  and  appear  oidy  on  the  surface  of  the  skin  without  rising  above 
it,  while  the  small-pox  consists  of  round  eminences.     When  these  eminences 
appear  fix  your  attention  on  them,  and  if  you  are  in  doubt  as  to  the  disease, 
do  not  express  any  opinion  about  it  for  a  day  or  two ;  but  when  there  arc  no 
eminences  you   must  not  give  as  your  opinion  that  the  disease  is  small-pox." 
Collie  declares:    ''A  case  of  small-pox   severe  enough  to  simulate  measles 
imparts  to  the  hand  in   passing  it  over  the  surface  a  hardness  and  furrowed 
roughness,  as  that  produced  in  passing  the  hand  over  a  piece  of  corduroy  ; 
whereas  in  raised,  confluent  measles  it  is  that  of  passing  the  hand  over  a  piece 
of  velvet."     Moore  gives  the  "  grisoUe  sign  "  as  a  certain  means  of  diagnosis : 
"If  upon  stretching  an  affected  portion  of  the  skin  the  papule  becomes  im- 
palpable to  the  touch,  the  eruption  is  caused  by  measles ;  if,  on  the  contrary, 
the  pai)ule  is  still  felt  when   the  skin  is  drawn  out,  the  erui)ti<)n  is  the  result 
of  small-pox."     The  catarrhal  symptoms,  more  especially  the  cory/.a,  which 
may  exist  in  both  affections,  are  wont  to  be  more  prominent  in  measles  at  the 
start,  but  persist  longer  in  small-i)ox.     The  course  of  the  temperature  is  cha- 
racteristic in  the  two  diseases.     The  fever  falls  in  small- pox  with  the  ai)pear- 
ance  of  the  eruption,  whereas  in   measles  it  remains  unalVected  or  may  rise 
higher.     The  appearance  of  papidcs  or  vesicles  soon  dissipates  all   idea  (.1' 

measles. 

The  sevoritv  of  the  sore  throat,  the  backache,  aud  the  s.-aHd  (-..lor  of  (he 
rash,  whicli  appears  as  minute  points  as  early  as  the  second  day  alter  the  ini- 
tial chill,  distinguish  scarlet  fever.  Th<'  grave  h.-.-inonhagie  f.-rm,  "  purpura 
variolosa,"  is  recognized  by  the  extreme  severity  of  pain  in  the  back,  as  well 
as  by  the  petechial  character  ol"  tii<-  eruption,  free  hfem..rrhages,  etc. 


280  SMALL- POX. 

Papular  eczema  is  irregular  in  its  distribution,  unattended  with  fever  or 
involvement  of  the  mucous  membranes.  The  same  exceptions  apply  to  ery- 
thema, acne,  and  herpes.  Only  the  most  superficial  observer  could  consider 
these  eruptions  variolous. 

Syphilis  may  show  pustules  to  closely  resemble  discrete  variola,  including 
even  the  process  of  umbilication,  but  the  absence  of  the  initial  signs,  chill, 
fever,  pain  in  the  back,  etc.,  the  history  of  syphilis  or  associated  evidence  else- 
where, render  the  diagnosis  easy  as  a  rule. 

All  cases  concerning  which  there  is  any  doubt  should  at  least  be  isolated 
for  a  time  until  sufficient  protection  can  be  offered  to  others  by  vaccination. 
Marson  says  of  his  experience  in  the  London  Small-pox  Hospital :  "  Upward 
of  twenty  diseases  have  been  mistaken  within  the  last  few  years,  in  the  early 
stage  of  the  disease,  for  small-pox,  and  the  patients  have  been  sent,  as  having 
small-pox,  to  the  small-pox  hospital."  The  separation  of  variola  and  varicella 
will  be  discussed  under  Varicella. 

The  progTiosis  is  largely  determined  by  the  last  successful  vaccination. 
The  next  most  important  factor  is  the  determination  of  the  form  of  the  dis- 
ease. The  third  is  the  age  of  the  patient.  Small-pox  in  infancy  has  a  mor- 
tality which  is  put  at  90  per  cent.  Almost  equally  grave  are  the  cases  which 
occur  in  pregnancy  and  the  puerperium.  The  greater  danger  which  is  thus 
imparted  to  the  female  sex  is  counterbalanced  in  the  male  sex  by  the  mortality 
of  the  disease  among  drinkers.  The  percentage  runs  high  again  in  advanced 
age :  nearly  75  per  cent,  of  old  people  unprotected  by  vaccination  or  previous 
attack  succumb  to  the  disease. 

Severe  symptoms  on  the  part  of  the  nervous  system  are  of  evil  omen,  but 
to  a  less  degree  in  children  than  adults.  Trousseau  laid  great  stress  upon 
tumefaction  of  the  extremities — what  he  called  *'  red  oedema  " — which  should 
set  in  at  the  end  of  the  ninth  day  with  acute  pain  ;  with  Sydenham,  Morton, 
Van  Swieten,  Borsieri,  he  attached  great  importance  to  it  in  a  prognostic  way. 
He  says :  "  Swelling  of  the  hands  and  feet  is  such  a  necessary  phenomenon  in 
confluent  small-pox  that  patients  almost  invariably  succumb  where  it  is  absent 
unless  there  be  a  great  critical  discharge  by  the  kidneys  or  bowels."  Profuse 
suppuration  in  the  skin  is  a  sign  of  danger.  Hemorrhagic  small-pox  is  very 
serious  ;  less  than  one-half  the  cases  recover.  The  prognosis  is  not,  however, 
unfavorable  because  of  initial  petechise,  which  may  show  later  upon  the  legs 
of  patients  who  try  to  get  about  too  soon.  Purpura  variolosa  is  always  fatal. 
The  mortality  of  the  unvaccinated  ranges,  even  in  our  day,  at  20-40  per  cent. 

Prophylaxis. — Vaccination,  if  it  could  be  enforced,  would  render  super- 
fluous all  other  prophylaxis,  including  isolation.  Inoculation,  which  it  substi- 
tutes, has  only  historic  interest.  Vaccination  and  revaccination,  if  they  could 
be  made  compulsory,  would  eventually  eradicate  {\\e  disease ;  thus  but  a  single 
fatal  case  of  small-pox  has  occurred  in  the  German  army  during  the  past 
fifteen  years.  Unfortunately,  however,  vaccination  cannot  be  made  com- 
pulsory in  our  country,  "where  the  cry  of  infringement  of  personal  liberty 
is  the  shibboleth  of  the  demagogue"  (Foster),  so  that  patients  must  still  be 


TREATMENT.  281 

isolated  aud  sick-rooms  disinfected.  A  temperature  of  400°  F.  is  fatal  to 
small-pox.  The  organisms  of  the  disease  are  destroyed  by  sulphur  in  suffi- 
cient concentration.  That  this  process  may  be  properly  brought  about,  it 
must  be  done  by  health  authorities.  All  combustible  material  should  be 
consumed  if  it  may  not  be  subjected  to  the  antimycotic  action  of  live 
steam  ;  walls  should  be  rubbed  down  with  bread,  and  floors  scrubbed  with 
a  solution  of  corrosive  sublimate,  1  :  1000 ;  doors  and  windows  should  be 
closed,  and  sulphur,  4  pounds  to  every  1000  cubic  feet  of  air,  should  be 
burnt  to  bring  about  perfect  fumigation  :  at  the  end  of  two  days  the  cham- 
ber may  be  thrown  open  and  thoroughly  ventilated  for  two  weeks.  Bedding, 
clothing,  curtains,  etc.,  after  subjection  to  superheated  steam,  should  be  sus- 
pended in  the  air  day  and  night  for  a  week.  The  dead  body  should  be  sub- 
jected to  immediate  interment,  as  infection  is  disseminated  from  its  surface 
up  to  the  period  of  decomposition.  In  the  interval  between  death  and 
burial  the  body  should  be  enveloped  in  a  sheet  saturated  in  the  solution 
of  corrosive  sublimate,  1:1000.  Transportation  should  be  permitted  only 
when  a  body  is  put  in  an  air-tight  metal  case.  In  the  experience  of  the 
author  an  endemic  was  once  developed  at  a  distance  in  a  country  town  by 
neglect  of  this  precaution. 

Treatment. — If  seen  early  the  patient  should  be  vaccinated  at  once.  Vac- 
cination in  the  early  stage  of  the  disease  modifies  variola.  After  the  fourth 
day  vaccination  is  useless.  Marson  puts  it  positively  :  "  Suppose  an  unvacci- 
nated  person  be  exposed  to  small-pox  on  Monday  ;  if  he  be  vaccinated  as  late 
as  Wednesday,  the  vaccination  will  be  in  time  to  prevent  small-pox  being 
developed;  if  it  be  ])nt  oif  until  Thursday,  small-pox  will  apj)ear,  but  will  be 
modified  ;  if  the  vaccination  be  deferred  until  Friday,  it  will  be  useless :  it 
will  not  have  had  time  to  reach  the  stage  of  areola,  the  index  of  safety,  before 
the  illness  of  small-[)ox  begins."  Curschmann  does  not  subscribe  to  these 
views.  He  declares  that  he  has  seen  in  cases  in  which  vaccination  was  prac- 
tised that  infection  with  vaccinia  and  small-pox  pustides  developed  side  by 
.side.  He  doubts  whether  vaccination  can  render  the  disease  even  milder  in  its 
course.  Nevertheless,  so  long  as  there  is  doubt  the  patient  should  have  the 
possible  benefit  of  early  vaccination. 

Treatment  in  the  absence  of  a  specific  is  wholly  symptomatic:  rest  in  bed 
in  a  thoroughly  ventilated  room  at  a  temperature  of  65°  F.,  as  determined  l)y 
a  thermometer  at  the  head  of  the  bed;  light  but  sufficient  covering;  cool 
drinks,  water,  lemonade,  seltzer- water,  in  sufiicient  (|nMntities  ;  fever  diet, 
milk,  sou[)s,  gruels.  This  nuich  we  owe  to  Sydenham.  \\'hat  it  must  have 
effected  may  be  learned  by  the  results  from  that  which  it  substituted.  The 
contrast  is  shown  in  a  chapter  from  the  ])ractice  of  Diemerbroek.  "  Keep  the 
patient,"  says  Diemerbroeck,  "in  a  chamber  close  shut  ;  if  it  be  winter  \v\  the 
air  be  corrected  by  large  fires;  take  care  that  no  cold  air  gets  to  the  patient's 
bed;  cover  him  ovev  with  blaid<ets.  Never  siiift  the  |)atient's  linen  till  after 
the  fourteenth  day,  for  fear  of  striking  in  the  pock,  to  the  irree(»veral>Ie  niiu 
of  the  patient.      Far  better  it  is  to  let  the  palieiil   lie.ir  with   the  stench   than 


282  SMALL-BOX. 

thus  be  the  cause  of  his  own  death."  Trousseau  is  right  when  he  says  :  "  If 
the  second  epoch  in  small-pox  was  introduced  with  inoculation,  and  the  third 
with  vaccination,  the  first  was  introduced  with  the  treatment  of  Sydenham." 

Fever  above  103°  F.  can  best  be  combated  by  frequent  baths  or  by  phenacetin, 
gr,  X,  or  antifebrin  or  antipyrine,  gr,  v,  or  in  half  of  these  doses  in  childhood. 
For  throat  complications  steam  from  an  atomizer,  simple  or  medicated  with 
boric  acid,  gr.  xv  to  fsiv;  thymol,  gr.  xv,  alcohol  and  water,  cid.  f  5ij  ;  or  carbolic 
acid  or  creasote,  3ss,  glycerin,  f  sj,  water,  §iij,  or  with  less  efficacy  gargles  of 
the  same  strength.  Inhalations  may  substitute  all  local  applications  in  very 
young  or  refractory  children.  Chloral,  gr.  ij-x,  becomes  a  necessity  in  periods 
of  unrest,  nervousness,  insomnia.  It  has  no  equal  in  the  relief  of  nausea  and 
vomiting.  For  jactitation  or  extreme  nervous  distress  it  may  have  to  be  sub- 
stituted by  Dover's  powder,  gr.  ij-v.  Frequent  ablutions  of  tepid  water, 
ointments,  diachylon  ointment,  plasters,  mercurial  plaster,  or  opening  pustules 
after  the  manner  of  the  Arabs  and  touching  them  with  nitrate  of  silver,  or 
better  carbolic  acid  and  glycerin  da.,  or  touching  the  tops  of  beginnwg  pus- 
tules— i.  e.  mature  vesicles — with  a  camel's-hair  brush  dipped  in  carbolic 
acid,  best  prevents  or  limits  pitting.  Xylol  internally  is  said  by  Ziilzer  to 
have  the  power  of  coagulating  the  contents  of  pustules,  but  the  claim  was  not 
at  all  substantiated  by  subsequent  trial.  Where  tissue  is  destroyed,  cicatriza- 
tion must  result,  and,  in  consequence  of  it,  pits  and  scars.  Means  to  prevent 
deformity  to  be  effectual  must  therefore  be  brought  into  use  before  the  stage 
of  suppuration  is  complete.  Nothing  can  prevent  ])itting  in  an  established 
confluent  small-pox.  The  best  clinicians  are  content  with  frequently  renewed 
water-dressings  made  antiseptic  as  much  as  may  be  with  sublimate  solutions, 
1  :  5000  or  1  :  10,000.  The  whole  question,  with  all  the  other  horrible  evils 
of  small-pox,  sinks  into  insignificance  and  slinks  away  like  the  devil  at  sight 
of  the  cross  when  brought  face  to  face  with  vaccination. 


VACCINATION. 

By  JAMES  T.  WHITTAKER. 


Vaccination  (from  vacca,  a  cow ;  vaccinia,  cow-pox)  is  a  terra  introduced 
from  France  to  express  the  inoculation  of  man  willi  cow-pox  in  prevention  of 
small-pox,  and  to  substitute  the  awkward  word  "cow-poxing,"  Tiie  promul- 
gation of  vaccination  by  ?]dward  Jenner  in  1798  constitutes  one  of  the  great 
epochs  in  the  history  of  maidvind,  in  that  from  this  period  the  terrible  tropical 
plague  variola,  which  overran  and  literally  ruined  Europe  and  the  rest  of  the 
world,  was  reduced  to  the  trivial  malady  varioloid,  which  is,  uncomplicated, 
never  fatal. 

Jenner  was  a  medical  apprentice  at  Sodbury  when  he  became  acquainted 
with  the  popular  belief  in  the  protective  influence  of  cow-pox;  and,  though  he 
was  unable  to  interest  his  preceptor,  the  celebrated  John  Huntei",  in  whose 
house  he  subsequently  lived  for  two  years,  or  to  convince  any  of  his  medical 
brethren  of  any  relation  or  antagonism  between  the  affections,  he  could  not 
dismiss  the  subject  from  his  mind.  He  visited  dairies  in  Gloucestershire 
and  made  observations  and  prosecuted  investigations  for  himself.  Pie  found 
that  there  existed  a  widespread  belief  among  the  dairymen  that  certain  indi- 
viduals, who  had  contracted  sores  upon  their  hands  from  contact  with  sores  on 
the  udders  of  cows,  were  never  attacked  with  small-pox.  Much  contradictory 
testimony  presented  itself  at  first,  and  many  disheartening  exceptions  were 
found.  If  genius  be  patience,  it  found  in  Jenner  an  example,  for  Joiner 
worked  with  this  subject  for  more  than  twenty  years  before  all  the  mighty 
truth  of  it  was  clear  to  his  mind. 

May  14,  1796,  was  the  memorable  day  when  Edward  Jenner  transferred 
cow-pox  from  vesicles  on  the  hands  of  Sarah  Nelmes,  a  dairymaid,  by  means 
of  two  superficial  incisions,  into  the  arms  of  James  Phip]>s,  a  hc:iltliy  boy  eight 
years  of  age.  The  cow-pox  ran  its  ordinary  course,  and  a  subse<(uent  inocula- 
tion with  small-pox  on  the  first  of  the  following  July  failed  to  produce  tlu' 
disease.  In  the  same  month  Jenner  wrf)te  to  his  intimate  frien<l  (iardncr  : 
"The  boy  has  since  been  inoculated  for  the  small-pctx,  which,  as  I  ventured 
to  predict,  producd  no  effect.  1  shall  now  pursue  my  investigations  with 
redoubled  ardor." 

This  was  tiie  first  attempt  of  a  sim|)le  praefice  which  has,  within  less  tli:in 
a  century  and  without  radical  correction  or  real  iin|)n>vciiien(,  anurdeil  to  all 
mankind  protection  fVoni  the  ravages  of  small-pox.  .leniier  was  led  to  make 
this  experiment  by  tlic  observation  that  individuals  accidentally  infected  with 

28;} 


284  VACCINATION. 

cow-pox,  to  use  his  own  words,  "  resisted  every  effort  to  give  them  small-pox." 
A  number  of  children,  subsequently  vaccinated  in  succession,  "  one  from  the 
other,"  were  after  several  months  exposed  to  the  infection  of  small-pox,  "  some 
by  inoculation,  others  by  variolous  effluvia,  and  some  in  both  ways,  but  they 
all  resisted  it."  Though  Jenner  was  himself  now  thoroughly  convinced,  he 
determined  to  withhold  his  conclusions  from  publication  until,  by  frequent 
repetition  and  fortification  in  every  direction  against  any  possible  error,  he 
might  establish  them  without  doubt.  He  repeated  his  inoculations  with  every 
precaution,  and  finally  prepared  his  pamphlet.  Hereupon  he  visited  London 
to  obtain  the  assent  and  support  of  his  medical  friends,  but  was  unable  for 
nearly  three  months  to  find  any  person  in  London  who  would  submit  to  the 
operation.  Finally,  on  his  return  home,  the  distinguished  surgeon  Cline 
introduced  vaccine  matter  over  the  diseased  hip-joint  of  a  child  as  a  means 
of  securing  counter-irritation.  When  he  found  later  that  this  child  had  thus 
secured  immunity  against  small-pox,  he  became  an  earnest  advocate  of  the 
operation,  and  a  supporter  of  Jenner  at  a  time  when  the  latter  stood  in  need 
of  one.  There  is  evidence  that  Jenner  worked  with  this  subject,  encounter- 
ing and  overcoming  obstacles  and  opposition  on  every  hand,  for  over  twenty 
vears  before  he  announced  his  results  to  the  world,  and  it  is  known  that  fully 
two  years  elapsed — a  delay  which  might  be  considered  culpable  in  our  day — 
between  the  first  vaccination  and  the  publication  of  his  paper.  The  paper  was 
modestly  entitled  an  "  Inquiry  into  the  Causes  and  Effects  of  the  Varioloe  Vac- 
cince,  a  Disease  discovered  in  some  of  the  Westerii  Counties  of  England,  par- 
ticularly Gloucestershire,  and  known  by  the  name  of  Cow-Pox,  London,  1798, 
4;  1800,  8;  1801,  8." 

Jenner  lived  to  see  all  opposition  overcome  and  the  procedure  adopted  all 
over  the  world,  and  to  receive,  with  universal  honors  and  emoluments,  from 
Parliament  in  1802  an  award  of  ten  thousand  pounds  (nearly  all  of  which 
Mas  lost  in  fees),  and  later,  in  1807,  a  second  allowance  of  twenty  thousand 
pounds.  In  1857  a  statue  was  erected  to  him  in  Trafalgar  Square  in  London. 
The  most  consummate  cynic  must  admit  that  up  to  the  present  time  Edward 
Jenner  has  been  the  greatest  benefactor  that  the  world  has  known. 

Intimations  of  the  protective  influence  of  cow-pox  had  been  made  here  and 
there  in  variou.s  parts  of  the  world,  especially  in  connection  with  dairies. 
People  in  different  places  had  believed  in  the  influence  of  this  protection,  and 
certain  individuals  had  actually  practised  it  upon  themselves  and  in  their 
families.  Such  statements  have  been  handed  down  from  Persia,  Scotland, 
and  Holstein,  but  they  made  no  impression  of  the  virtue  and  secured  no  adop- 
tion of  the  practice  of  vaccination  up  to  the  time  when  a  country  milkmaid 
said  to  Jenner  during  his  student-life  at  Sodbury,  "  I  cannot  have  the  small- 
pox, for  I  have  had  cow-pox."  This  statement  repeated  itself  and  rang  in  his 
ears  for  over  twenty  years.  It  left  him  no  rest  until  it  resulted  in  the  discov- 
ery of  the  protection  of  mankind,  and  but  for  the  stupidity  of  men  would  have 
long  since  led  to  the  exter^iination  of  the  disease. 

Vaccine  matter  was  soon  carried  all  over  the  world.     The  Spanish  govern- 


VACdXAriOX.  28-3 

ment  sent  ships  atul  surgeons  to  all  its  possessions  in  the  Okl  and  Xew  Worlds. 
The  expedition  made  circuit  of  the  entire  globe  in  the  course  of  three  years. 

The  operation  was  first  performed  in  this  country  by  Prof.  Waterliouse  of 
Cambridge,  and  in  the  same  year  (1801)  was  practised  in  his  own  family  by 
Jetferson,  then  President  of  the  United  States.  The  Empress  baptized  the  first 
child  vaccinated  in  Russia  with  the  name  "  Yaccinotf,"  and  gave  it  govern- 
ernment  endowment.  The  nations  of  the  earth  vied  with  each  other  in  tributes 
to  Jenner  and  demonstrations  of  joy.  Napoleon  Bonaparte  took  his  signature 
as  a  passport.  The  anniversaries  of  the  first  operation  and  that  of  the  first 
vaccination  were  celebrated  in  Germany — in  a  special  temple  at  Brunn, 
Moravia — as  the  Churcii  celebrates  its  saints,  with  holidays,  and  our  own 
Indians  sent  with  belt  and  wampum  a  declaration  that  ''we  shall  not  fail  to 
teach  our  children  to  speak  the  name  of  Jenner  and  to  thank  the  Great  Spirit 
for  bestowing  upon  him  so  much  wisdom  and  benevolence." 

Jenner  spent  the  rest  of  his  life  in  the  perfection  of  his  discovery.  His 
practical  conclusions  remain  impregnable.  In  theory,  however,  he  fell  into 
two  slight  errors  :  one,  the  belief  that  cow-pox  would  protect  for  life — a  belief 
that  led  later  to  some  doubt  regarding  its  protection  in  general;  the  other,  that 
the  disease  was  conveyed  to  the  cow  from  the  horse  bv  individuals  eno-atred 
in  the  double  duty  of  hostlers  and  milkmen.  A  disease  of  the  horse's  hoofs, 
commonly  known  as  "the  grease,"  when  conveyed  to  the  bag  of  a  cow  pro- 
duces an  eruption  which  simulates,  but  which  subsequent  investigation  has 
shown  to  be  not  identical  with,  the  true  cow-pox.  The  belief  that  cow-pox 
is  modified  human  small-pox  found  much  wider  acceptance,  and  has  few 
opponents  in  the  present  day.  These  opponents  maintain,  however,  that  the 
doctrine  is  dangerous,  and  that  it  has  been  the  cause  of  insufficient  protection, 
and  therefore  injury  to  vaccination,  as  well  as  directly  of  death  by  the  propa- 
gation of  small-pox  itself. 

Cow-pox  is  an  infectious  disease  which  appears  in  dairies  from  time  to 
time,  often  at  wide  intervals  of  both  time  and  space,  and  shows  itself  first  in 
some  particular  cow,  usually  a  young  cow,  a  heifer  in  her  first  milk.  It 
never  appears  first  in  other  cattle  than  milk  cows,  and  never  shows  itself 
elsewhere  than  on  the  teats  or  at  adjoining  parts  of  the  bag,  as  they  may  be 
infected  by  direct  pressure  or  contact.  It  appears  in  the  foriu  of  scattered 
papules,  which  in  the  course  of  a  few  days  show  fluid  at  their  ai)ices,  to 
become  transformed  into  distinct  vesicles.  These  vesicles  are  broken  by 
the  hands  of  the  milkers,  and  the  disease  is  thus  disseminated  in  the  coiu'se 
of  a  few  weeks,  sometimes  months,  throughout  the  entire  dairy.  After 
rupture  the  fluid  of  the  vesicle  thickens  to  form  a  cnisl,  under  which  the 
eroded  tissue  or  ulcer  cicatrizes,  produ(!ing  a  sear  with  indurated  margins  and 
puckered  surface.  Uncleanly  dairymen  often  infect  other  parts  of  their  own 
bodies  with  their  hands.  Jenner,  Ceely,  and  Pearson  described  such  eases  of 
infection  of  the  lij>s,  side  of  tlie  nose,  (em|)le,  etc. 

In  January,  1799,  Woodville  of  the  Fiondon  Small-pox  Hospital  succeeded 
in  storing  a  supply  of  pure   material,  from  which  source  Jemier,  with  several 


286  VA  CCINA  TION. 

hundred  practitioners,  got  their  vaccine  matter.  This  Woodville  stock  was 
then  used  all  over  the  world  up  to  1836.  At  about  this  time  matter  began  to 
be  introduced  from  other  sources  :  first,  from  the  Passy  cow  in  1836,  and  here, 
again,  from  the  accidental  infection  of  the  hands  of  a  milker.  Material  from 
these  vesicles  started  a  new  stock,  which  was  subsequently  used  in  France.  By 
1838  the  new  disease,  vaccinia,  was  so  far  forgotten  in  Jenner's  own  parish, 
Berkeley,  Gloucestershire,  that  the  milkers  were  ignorant  of  the  cause  of  the 
appearance  of  vesicles  upon  their  own  hands.  From  these  vesicles  Estlin  of 
Bristol  established  a  new  geniture.  Next  Ceely  of  Aylesbury  (1838-41)  dis- 
covered half  a  dozen  cases  of  cow-pox  in  dairy-farms  of  his  district,  and  cul- 
tivated lymph  from  them.  In  1866  the  disease  was  discovered  in  Beaugency, 
and  this  source  furnished  lymph  for  the  inoculation  of  calves,  which  was  now 
practised  as  a  regular  business  in  Dutch,  Belgian,  and  other  vaccine  farms. 
Genuine  cow-pox  has  since  been  discovered  and  described  in  Holland,  Italy, 
Bengal,  South  America,  Mexico,  New  England,  Pennsylvania,  and  California; 
and  there  can  be  no  doubt,  as  Seaton  says,  that  "  much  more  would  be  found 
than  really  is  found  if  only  looked  for." 

The  first  case  of  kine-pox  in  the  United  States  was  reported  by  Dr.  John 
Yale  of  Ware,  Mass.,  as  observed  at  Torringford,  Conn.  (1844),  and  at  Ware, 
Mass.  (1855),  the  true  nature  of  the  pox  having  been  established  at  Ware  by 
inoculation  of  man  as  well  as  by  propagation  in  calves.  Martin  of  Massa- 
chusetts established  the  first  well-equipped  vaccine  farm  in  the  United  States 
in  1870,  with  the  inoculation  of  a  constant  succession  of  heifers.  He  was 
followed  by  Foster  of  New  York  and  Griffin  of  Fond  du  Lac  in  Wisconsin. 
Vaccinifers  from  these  farms  furnish  nearly  all  the  lymph  used  in  this 
country. 

A  disease  attended  with  eruption  of  vesicles  and  pustules  occurs  in  many 
animals  besides  the  cow,  as  in  the  horse,  sheep,  goat,  dog,  etc.  Sometimes  the 
eruption  is  general,  sometimes  local.  In  some  cases  the  disease  is  marked  by 
ulcers,  in  others  by  glandular  enlargements,  etc.  In  some  animals  the  disease 
is  trivial,  in  others  dangerous  and  often  fatal.  Cow-pox  differs  from  all  other 
kinds  of  pox  in  that  the  disease,  as  stated,  is  confined  almost  exclusively  to 
female  animals  at  the  time  of  lactation,  and  the  eruption  is  confined  to  the  bag. 
After  a  period  of  incubation  of  three  or  four  days  the  eruption  appears  as  red 
spots,  which  speedily  swell  to  assume  the  form  of  pa])ules,  become  converted 
into  vesicles  by  the  fifth  or  sixth  day,  to  be  transformed  into  pustules  by  the 
tenth  day.  The  pustules  in  full  development  ai'e  present  to  the  number  of 
twenty  or  thirty  as  fully-rounded  bodies,  slightly  depressed  in  the  centre,  and 
often  urabilicated.  Sometimes  they  remain  flat,  with  no  central  depression,  their 
presence  being  then  easily  overlooked.  A  vesicle  or  pustule  is  not  a  single 
sac,  but  a  set  of  chambers,  puncture  of  which  does  not  permit  the  escape  of 
all  the  contents,  and  the  full  discharge  of  which  can  be  secured  only  by  pres- 
sure. The  })ustules  dry  to  form  crusts,  which  fall  on  the  twelfth  to  the  fif- 
teenth day,  to  leave  oval  or  rounded  scars  which  persist  for  years. 

It  is  characteristic  of  cow-pox  to  appear  also  in  successive  eruptions.     Not 


VACCIXATIOX.  287 

infrequently  vesicles  and  pustules  appear  side  by  side  with  dry  crusts.  Indi- 
vidual vesicles  run  their  course  in  five  or  six  days,  but  the  whole  disease  is 
a  subacute  and  chronic  process,  lasting  often  for  several  months.  The  disease 
causes  in  the  cow,  as  a  rule,  no  sign  of  general  distress,  but  sometimes  there 
are  fever  and  loss  of  appetite ;  occasionally  there  are  quantitative  and  qualita- 
tive alterations  in  the  milk. 

The  discovery  of  the  origin  of  genuine  cow-])ox  has  always  been  a  fasci- 
nating study.  The  characteristic  course  of  the  disease  unmistakably  gives  it 
place  among  the  infections,  so  that  there  can  be  no  question  whatever  of  sj)on- 
taneous  origin  or  generation.  Inasmuch  as  the  disease  occurs  only  at  intervals, 
it  cannot  be  sustained  by  continuous  succession,  so  far  as  the  cow  alone  is  con- 
cerned. It  must  therefore  arise  from  some  otiier  animal  or  from  man.  Jenner 
considered  it  to  be  derived,  as  stated,  from  the  horse,  but  this  origin  is  now  no 
longer  considered  tenable,  as  it  breaks  out  in  dairies  where  there  are  no  horses, 
and  occurs  in  places  where  horse-pox,  as  in  Germany,  is  almost  unknown. 

The  accumulated  observations  of  a  century  reveal  the  fact  that  there  are 
but  two  chief  forms  of  small-pox — to  wit,  human  pox  and  sheep-pox.  They 
both  attack  the  multitude,  they  both  assume  pandemic  range :  one  is  a  genuine 
epidemic,  the  other  a  genuine  epizootic.  All  other  varieties  of  pox — that  of 
the  horse,  cattle  (including  cow-pox),  of  swine,  goats,  and  dogs — constitute, 
as  Bollinger  proves,  no  distinct  individual  disease.  They  are  to  be  regarded 
onlv  as  irregular  forms  of  the  primary  human  or  sheep-pox  modified  in  dif- 
ferent animals.  Whether  man  got  the  pox  from  sheep  or  sheej)  from  man  is 
a  question  that  may  never  be  determined,  but  the  best  authorities  (Bohn  and 
Bollinger)  unreservedly  maintain  that  the  virus  is  identical  in  the  two  cases — 
identical  and  interchangeable.  The  corollary  of  this  fact  determines  the  origin 
of  cow-pox.  Cow-pox  is  in  its  essence  variola  vera.  It  is  variola  modified  in 
the  body  of  the  cow.  If  vaccinia  be  but  an  attenuated  or  modified  variola,  its 
protective  action  ceases  to  be  a  mystery.  It  protects  by  the  immunity  of  pre- 
vious attack.  It  protects  by  the  immunity  of  inoculation — i.  e.  variolation  ; 
for  vaccination  is  variolation  with  virus  robbed  only  of  its  virulence. 

On  the  other  hand,  it  is  alleged  that,  first,  the  processes  are  not  similar — 
vaccinia  remains  always  a  local,  variola  a  general  disease ;  second,  one  process 
never  produces  the  other — vaccinia  always  produces  vaccinia,  as  variola  always 
produces  variola.  Fatal  cases  have  ensued  in  man  after  the  use  of  matter  from 
the  cow  inoculated  with  the  small-pox  of  man  (Chauveau). 

According  to  Bohn,  Gassner  of  Gun/.burg  (1807)  was  the  first  to  inoculate 
the  cow  with  the  small-pox  of  man.  He  iiitroduced  small-pox  matter  from 
the  vesicles  of  children  in  a  number  of  cattle.  The  o|)eration  succeeded 
eleven  times.  With  the  contents  of  vesicles  so  fin-med  he  vaccinal.d  fmir 
children.  They  developed,  without  excejjtion,  ])erfect  vac<Miii:i  piistiihs. 
This  operation  was  subsequently  ]>ractise(!  on  a  hirge  scale  by  Thiclc  of 
Kasan  and  Ceely  of  England  (18.".8).  They  inocidated  cows  on  the  bag  :iii<i 
vulva  with  human  variola,  with  the  develoi)nicnt  in  every  ea<e  of  cow-pox, 
which  was  alwavs  localized  at  the  point  of  inoculation.  an<l  \vlii<li  was  never 


288  VACCINATION. 

followed  by  general  eruption.  Matter  derived  from  these  pustules  in  the  cow, 
introduced  upon  the  arras  in  children,  produced  the  same  result  as  matter  from 
the  common  cow-pox.  Thiele  carried  his  new  matter  through  seventy -five 
human  generations  in  more  than  three  thousand  persons,  and  proved  its 
thoroughness  by  subsequent  inoculation  with  genuine  variola  humana  in 
twenty-one  cases.  Ceely  carried  his  matter  through  more  than  sixty  genera- 
tions in  over  two  thousand  people,  and  tested  its  value  in  the  same  way,  with 
numerous  inoculations  with  small-pox  matter.  These  experiments  were  mul- 
tiplied by  Badcock,  Senfft,  and  others  until  they  seemed  to  have  established, 
beyond  doubt,  the  identity  of  variola  and  vaccinia.  These  conclusions  were, 
however,  controverted  by  the  committee  of  Lyons,  consisting  of  Chauveau, 
Viennois,  and  Meynet,  who  maintained  (1865)  that  the  cow  was  incapable  of 
changing  variola  into  vaccinia,  and  that  the  inoculation  of  variola  only  repro- 
duced itself.     The  Turin  committee  (1874)  reached  the  same  conclusions. 

As  Bollinger  states,  however,  any  number  of  negative  results  cannot  over- 
throw positive  results.  Much  depends  upon  the  mode  of  inoculation  and  the 
character  of  the  animal  operated  upon.  How  else  could  it  happen  that  Senift 
got  only  positive  results  with  all  his  calves?  While,  from  occasional  mis- 
takes, some  accident  might  occur  in  the  reinocculation  of  man  with  matter 
thus  derived  from  the  cow,  when  ordinary  precautions  were  observed  the 
operation  was  always  successful  (B.  Reiter,  Kranz). 

These  cases  do  not,  however,  entirely  explain  the  origin  of  cow-pox,  for 
this  disease  may  prevail  in  cattle  independently  of  variola  humana.  Examples 
of  coincidences  have  been  noticed  (Dinter,  Saxony,  1860 ;  Bollinger,  Holzstein, 
1871),  but  they  are  rare,  and  cow-pox,  since  the  practice  of  vaccination,  is 
much  more  frequent  than  small-pox.  The  frequency  of  cow-pox  is  explained 
by  the  fact  that  the  disease  is  given  back  to  the  cow  by  humanized  matter. 
Scarcely  two  decades  of  years  had  lapsed  after  its  discovery  until  vaccination 
became  universal,  so  that  the  frequency  of  genuine  cow-pox  in  our  day  is 
explained  by  accidental  inoculation  with  humanized  vaccinia.  Under  these 
circumstances  it  is  a  matter  of  secondary  importance,  so  far  as  the  protective 
efficacy  of  the  virus  is  concerned,  whether  so-called  animal  or  human  lymj)h 
be  employed  in  vaccinating,  for  it  is  the  same  virus  in  every  case.  Animal 
lymph  "  takes "  slower  and  harder,  but  compensates  for  these  objections  by 
freedom  from  any  possible  infection  with  tuberculosis,  syphilis,  or  other  disease, 
excepting,  possibly,  erysipelas. 

No  fact  is  better  attested  than  this  protection  in  the  case  of  small- 
pox. The  proof  of  the  degree  of  it  is  seen  at  a  glance  by  observation 
of  statistics  in  countries  and  cities  where  they  are  most  accurately  kept. 
Thus  in  Sweden  the  mortality  from  small-pox  in  the  twenty-four  years 
before  the  introduction  of  vaccinia  (1801)  was  2050  per  1,000,000  annu- 
ally ;  after  vaccination,  158  per  1,000,000.  Drysdale  says  of  Berlin  that 
the  mortality  in  that  city  during  the  epidemic  of  1872-73  rose  to  243 
and  262  respectively  per  100,000  inhabitants.  Thereupon  vaccination  in 
the  first  year  of  life  was  made  compulsory,  and  revaccination  in  the  twelfth 


VA  CCINA  TIOX.  289 

year  of  life,  with  the  result  that  in  the  first  year  of  enforcement  (1875)  the 
mortality  fell  to  3.G  per  100,000;  to  3.1  in  the  year  1876;  to  0.3  in  1877; 
and  so  on  for  succeeding  years,  down  to  1883,  with  an  average  of  1.7  per 
100,000.  (See  Fig.  21.)  The  nearly  absolute  protection  of  vaccination  is 
shown,  again,  by  comparison  of  cities  in  which  vaccination  and  revaccination 
are  obligatory  and  optional.  Thus,  according  to  the  recent  reports  of  the 
Berlin  Health  Office  the  mortality  of  small-pox  per  100,000  inhabitants  in 
1888  was  in  Dresden,  0;  in  Berlin,  0.07;  in  Limdon,  0.6;  in  Munich, 
0.75;  in  Hamburg,  3.58  ;  in  Paris,  9  ;  in  St.  Petersburg,  15.30;  in  Vienna, 
26.15;  in  Prague,  55.49.  Corbally  reports  that  the  vaccinated  children  of 
Sheffield  (1887-88)  had,  as  compared  with  the  unvaccinated  children,  a 
twenty-fold  immunity  from  attack,  and  a  four-hundred-and-eighty-fold  secur- 
ity against  death  by  small-pox.  These  facts  render  further  statements  super- 
fluous, but  a  few  points  may  be  added  from  army  life.  Army  statistics  are 
especially  valuable  from  their  accuracy.  Thus,  Schultze  shows  that  since  the 
operation  of  the  German  law  the  annual  average  cases  of  small-pox  })er  100,000 
was  in  the  army  of  Germany,  4.94;  of  France,  169.72;  of  Austria,  374.0. 
During  the  Franco-German  War  (1870-71)  the  mortality  of  small-pox  in 
the  unvaccinated  French  army  was  23,469,  while  that  of  the  vaccinated 
German  army  was  but  261.  As  already  stated  elsewhere,  there  has  been 
reported  but  one  case  of  death  from  small-pox  in  the  German  army  since 
1874.  Morbidity  shows  the  same  results  as  mortality  statistics:  for  since 
the  enactment  of  the  compulsory  law  in  Germany  (Schultze)  there  have 
been  attacked  with  small-pox  annually  : 

In  the  German  army,  up  to  1887,  4.2. 

In  the  French  army,       "     1886,  169.0. 

In  the  Austrian  army,     "     1881,  317.5. 

The  immunity  conferred  by  vaccination  does  not,  as  Jenner  hoped,  last  for 
life.  Therefore,  revaccination  becomes  a  necessity  after  a  lapse  of  years.  The 
best  proof  of  this  necessity  is  furnished  in  the  fact  that  revaccination  *' takes" 
as  a  rule;  thus,  among  the  soldiers  of  Prussia,  Russia,  and  Denmark  it  was 
successfid  in  50—70  per  cent,  of  cases.  Heim  found  in  five  years  but  1  ca.se 
of  varioloid  among  14,384  revaccinated  soldiers,  and  but  1  ca.se  among 
30,000  civilians,  small-pox  meanwhile  prevailing  in  three  hundred  and  forty- 
four  places  in  which  these  people  lived. 

Moreover,  the  number  of  epidemics  has  diminished  from  71.4  j)er  cvulury 
previous  to  vaccination,  increased  to  84  during  inocidation,  to  iiiU  to  24  sincc^ 
vaccination.  Protection  be<>;ins  on  the  fourth  dav  after  the  introduction 
of  the  virus,  and  is  perfect  on  the  ninth  day.  The  degree  of  protection, 
indej>endent  of  revaccination,  is  determined  to  a  consi<lei-able  extent  by  th(» 
success  of  the  operation  and  by  the  quantity  of  matter  introduced — i.e.  by  the 
number  of  ]>laces  vaccinatctl.  Thus,  according  to  Marsoii,  the  aver.-ige  mor- 
tality of  small-pox  among  all  vaccinated  persons  is  5.24  per  cent.,  while  that 
of  individuals  showing  j)erfect  cicatrices  is  about  .5  per  cent.  In  6000  cases 
of  small-pox  after  vaccination  observed  by  Simon  in  twenty-five  years  the  per- 
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VA  CCI^''A  TIOX.  29 1 

centage  of  deaths  among  individuals  without  cicatrices  was  21.75  percent.; 
with  one  indefinite  cicatrix,  12  per  cent. ;  with  one  typical  cicatrix,  4.25  per 
cent. ;  with  two  cicatrices,  4.125  per  cent. ;  with  three  cicatrices,  75  per  cent. ; 
with  four  or  more  cicatrices,  .25  per  cent.  This  fact  finds  additional  proof 
in  the  observation  that  the  protection  of  vaccinatit)n,  however  great,  is  not 
so  thorough  and  sustained  as  that  oifered  by  an  attack  of  small-pox  itself, 
whether  contracted  by  ordinary  exposure  or  by  inoculation.  Vaccination  and 
revaccination  once  or  twice  in  later  life,  as  at  puberty  and  maturity,  protect  for 
life  absolutely.  The  exact  duration  of  protection  by  a  single  vaccination  can- 
not be  definitely  established.  It  varies  in  different  cases.  If  revaccination 
"takes,"  the  individual  was  certainly  liable  to  take  small-pox.  The  operation 
is  so  simple  and  inexpensive  as  to  justify  its  practice  at  stated  intervals, 
and,  inasmuch  as  no  case  of  small-pox  contracted  within  seven  years  after  a 
successful  vaccination — twelve  in  Germany,  according  to  report  of  the  health 
office — stands  upon  authentic  record,  this  period  may  be  put  down  as  the 
proper  interval  for  absolute  protection,  with  the  injunction  in  all  cases  that 
revaccination  be  performed  with  every  exposure  seven  years  after  the  last  suc- 
cessful vaccination. 

The  history  of  vaccination  would  be  incomplete  without  at  least  mention 
of  its  forerunner,  inoculation,  which  has  now  closer  conneclion  with  or  rela- 
tion to  vaccination  than  ever  before.  No  fact  could  better  exemplify  the  lack 
of  intercourse  with  the  nations  of  the  East  than  the  ignorance  of  Europe  of 
the  practice  of  inoculation  in  China  and  India  for  three  thousand  years.  The 
first  knowledge  of  its  protective  effects  was  introduced  into  Europe  by  letters 
from  the  literary  celebrity,  Lady  Mary  Wortloy  INIontagu,  wife  of  the  Eng- 
lish ambassador  at  Constantinople.  She  was  a  personal  witness  of  the  method 
of  jirocedure  as  well  as  of  its  effects,  and  became  an  enthusiastic  advocate  of 
its  protective  virtue.  On  her  return  to  England  she  had  her  own  daughter 
inoculated  with  small-pox  matter.  As  the  practice  was  opposed  by  men  of 
high  repute,  she  succeeded  in  interesting  the  government  in  her  defence  to  the 
extent  that  a  promise  of  pardon  was  granted  to  six  criminals  condemned  to 
death  if  they  would  consent  to  the  operation.  It  need  hardly  be  stated  that 
consent  was  readily  given,  and  that  the  men  thereby  secured  double  release. 
In  the  following  year  the  two  daughters  of  the  |)rincess  of  Wales  were  pro- 
tected in  the  same  way.  Meanwhile  (1721)  small-pox  was  raging  in  Boston, 
where  inoculation  was  speedily  introduced.  It  has  already  been  >la(('il  that 
inoculators  were  most  successful  when  they  practised  the  operation  at  periods 
exempt  from  the  prevalence  of  the  disease.  The  history  of  inoculation  in 
Boston  relates  the  disadvantage  of  inoculation  during  the  period  of  picva- 
loncy,  for  it  proved  fatal  in  six  cases.  Several  deaths  of  prominent  ju-rsons 
in  England  occurred  at  about  the  same  time,  to  check  pre<'i|)italely  the  spread 
of  the  new  practice.  A  quarter  of  a  century  now  elapsed  belbrc  llu'  (.juration 
was  practised  in  any  systematic  way  in  pul)lie  institutions  where  tlic  poor  as 
well  as  the  ricji  might  reeeive  its  benefits.  The  LonddU  Small-pox  aixl  Inocu- 
lation Hospital   was  not  founded  until  17-40.     During  the  following  half  cen- 


292  VA  CCINA  TION. 

tury  it  was  the  fashion  to  be  inoculated.  People  made  engagements  with  the 
inoculators  as  they  now  do  with  the  dentists.  The  wife  of  General  Washing- 
ton during  a  visit  to  Philadelphia  took  advantage  of  her  visit  to  undergo 
inoculation,  in  which  process  she  had  "a  very  favorable  time"  (Plant). 

There  was  no  doubt  of  the  protection  of  the  individual  by  inoculation. 
The  proportion  of  deaths  was  reduced  from  20  or  40  per  cent,  to  3  in  1000. 
There  was,  however,  another  side.  The  disease  which  was  introduced  was  the 
true  small-pox,  and  each  inoculated  person  was  a  centre  for  infection.  By  the 
end  of  the  eighteenth  century,  when  the  practice  of  inoculation  had  become 
general,  the  proportion  of  deaths  from  small-pox  to  deaths  from  all  causes  had 
increased  from  one-fourteenth  to  one-tenth.  With  the  recognition  of  this  fact 
the  process  was  interdicted  by  law  both  in  England  and  France.  This  was  in 
1841,  but  inoculation  was  still  secretly  practised,  with  the  continued  produc- 
tion of  new  centres  of  small-pox,  until  the  government  affixed  to  it  as  late  as 
1860  a  penalty  of  fifty  pounds. 

Something  of  the  nature  of  vaccinia-lymph  may  be  learned  by  study  of  this 
'^  history  of  inoculation.  As  has  been  stated  already,  it  was  the  custom  in 
China  and  India  three  thousand  years  ago  to  directly  produce  the  disease  by 
inoculation  of  small-pox  matter  itself,  and  secure  protection  by  immunity  thus 
conferred  by  previous  attack.  It  was  the  custom  in  Europe,  as  also  in  the 
early  history  of  our  own  country,  to  isolate  people  in  a  period  of  health  in 
pest-houses,  and  directly  inoculate  or  engraft  them  with  the  disease  itself,  in 
the  hope  that  the  introduction  of  the  poison  at  a  period  free  from  the  presence 
of  an  epidemic  would  produce  a  milder  form  of  the  disease.  Some  of  the 
older  variolators  became  exceedingly  expert  in  this  operation.  Gatti,  the 
**  Jenner  of  inoculation,"  brought  it  to  a  grade  of  perfection  worthy  of  being 
called  a  science.  He  was  certainly  able  in  a  large  percentage  of  his  cases 
to  bring  about  a  variola  so  modified  as  to  be  distinguished  at  times  by 
the  absence  of  any  general  eruption,  and  sometimes  by  the  'absence  of  all 
eruption.  He  selected  his  subjects  and  season  of  the  year  as  well  as  his 
stock  of  matter.  He  learned  to  make  the  the  smallest  possible  wound  with- 
out drawing  blood,  and  to  introduce  his  matter  in  minimum  quantity.  He 
selected  it  also  from  the  oMest  case,  convinced  of  the  fact  that  the  poison  was 
mitigated  by  continuous  generation.  This  mitigation  of  the  intensity  of  the 
poison  is  the  clue  and  the  key  of  the  whole  process  of  securing  immunity 
against  the  various  infections  in  modern  times,  the  results  of  which  promise 
to  soon  eradicate  or  modify  the  forms  of  these  diseases.  It  was  learnt  by  acci- 
dent that  the  mitigation  of  small-pox  virus  was  precipitated  by  passing  it 
througli  the  body  of  a  cow.  At  the  present  time  there  is  no  doubt  that  the 
original  cow-pox  is  human  pox  modified  in  this  way.  It  is  Avell  known  also 
that  variola  virus  may  be  attenuated  in  other  ways.  Thiele  of  Kasan  in  the 
systematic  desiccation  of  genuine  small-pox  matter,  dilution  with  milk,  inocu- 
lation, propagation,  redilution,  etc.,  through  several  generations,  succeeded  in 
producing  a  virus  whose  properties  Avere  absolutely  identical  in  every  way 
with  the  vaccinia-lymph  in  common   use.     In   fact,  the  process  of  generation 


VA  CCINA  TION.  293 

can  be  continued  so  far  as  to  destroy  all  infectious  properties.  This  fact  was 
observed  long  ago  in  bovine  virus,  which,  when  continuously  transmitted 
from  calf  to  calf,  finally  loses  its  protective  property.  To  sustain  the  virtue 
of  bovine  lymph  occasional  resort  to  inoculation  of  the  animal  with  human 
matter  became  a  necessity.  The  antiseptic  fluids,  carbolic  acid,  salicylates, 
solutions  of  boric  acid,  thymol,  etc.,  added  to  vaccine  virus  for  preservation, 
gradually  reduce  its  active  properties;  so  too  chemically  pure  glycerin,  which 
is  added  for  dilution,  has  the  same  eifect  of  weakening  and  finally  destroying 
the  active  principle. 

The  best  lymph  from  the  cow  is  that  which  exudes  from  perfect  vesicles 
before  they  begin  to  point.  The  presence  of  slight  incrustation  in  the  centre 
of  the  vesicle  indicates  the  period  of  greatest  virtue.  The  puncture  should  be 
made  with  a  sharp  lancet  as  near  the  centre  of  the  vesicle  as  possible,  and  the 
fluid  collected,  as  it  exudes  spcmtaneously  or  under  slight  pressure,  in  capillary 
tubes  or  upon  the  surface  of  bone  points.  Puncture  of  the  margin  of  the 
vesicle  secures  only  blood,  which  is  worthless.  "  Vesicles  on  which  the  central 
crust  has  begun  to  form  are  the  most  productive,  particidarly  if  the  crust  be 
small  and  the  margin  of  the  vesicle  tender,  hot,  and  tumid  :  the  small  super- 
ficial vesicles  are  often  more  yielding  than  contiguous  larger  vesicles,  which 
are  more  deeply  seated  or  confluent"  (Aitken). 

Supply  is  now  so  abundant  and  is  furnished  from  so  many  sources  as  to 
secure  mankind  against  any  accident  by  extinction  of  the  natural  disease.  No 
place  is  so  distant  from  a  vaccine  farm  that  it  may  not  be  sujiplied  in  the 
course  of  a  few  days  or  a  week  with  effective  material.  In  emergency,  where 
a  i)ure  lymph  cannot  be  secnn-cd,  that  which  has  undergone  some  degree  of 
incrustation,  as  aggregated  lymph  found  in  the  immediate  vicinity  of  broken 
vesicles,  may  be  used  as  a  substitute.  It  should  be  clear  and  colorless  like 
crystals  of  white  sugar  candy,  or,  if  colored,  but  lightly  tinged  with  amber. 
Central  crusts  which  represent  a  mass  or  mould  of  vesicles,  dark  brown,  but 
nearly  translucent,  may  also  be  used.  The  crust  should  be  pulverized  in  a 
clean  mortar  and  preserved  in  glycerin. 

Where  human  lymph  is  used  vaccination  is  best  practised  from  arm  to 
arm.  The  vesicle  is  punctured  at  the  period  of  full  maturity  on  the  eighth 
dav,  never  later,  and  the  clear  fluid  which  exudes  is  collected  and  utilized  as 
before.  Before  the  general  use  of  bovine  virus  the  material  mostly  employed 
was  the  crust  which  fell  spontaneously  from  a  healthy  child.  This  crust  was 
treated  in  the  same  way  as  that  from  bovine  lymph.  Protected  from  the  air, 
enveloped  in  rubber  cloth  and  absorbent  cotton,  and  enclosed  in  well-stoi)i)ed 
vials,  it  retains  its  efficacy  for  almost  indetinite  periods.  Thus,  Miiller  of 
Berlin  (1869)  made  use  of  cow's  lymph  which  had  been  originally  sent  fnmi 
Holland  for  the  purpose  of  experimentation,  and  had  been  kept  <Iry  between 
apposed  glass  plates  for  ten  years,  with  perfect  success.  The  virlne  of  the 
lymph  is  preserved  also  under  considerable  dilution.  I^ymph  is  usually  kept 
diluted  in  two  parts  glvecrin  and  two  parts  distill<-<l  water,  the  mixture  being 
made  by  means  of  a   small   brush  and  a  watch-glas.s.     Miiller  found  that  this 


294  VA  CCINA  TION. 

fluid  could  be  further  diluted  to  one  part  to  eight  without  sacrifice  of  virtue.  In 
greater  dilutions  it  begins  to  lose  protective  property,  but  vaccination  with  one 
part  lymph  and  two  hundred  of  distilled  water,  if  used  in  abundance,  "  took  " 
as  a  rule.  Much  depends  also  upon  the  extent  of  surface  inoculated.  Thus, 
Eeiter  found  the  use  of  a  dilution  1  :  1600  successful  after  introduction  upon 
the  surface  of  an  extensive  abrasion.  Charpie  saturated  in  this  solution  and 
applied  to  the  surface  of  a  blister  produces  definite  results.  These  facts 
account  for  the  diverse  statements  of  different  observers.  Thus,  Hillier  found 
a  dilution  of  1  :  10  in  glycerin  inactive,  while  Chauveau  succeeded  with  a 
dilution  of  1  :  150  of  water. 

Failures  to  secure  results  diminish  in  every  decade.  Thus,  up  to  1872  the 
proportion  of  failures  to  success  was  1  to  120;  up  to  1876,  1  to  129;  up  ta 
1880,  1  to  280  (Cless). 

The  discovery  of  the  nature  of  vaccine  virus  and  the  mode  of  infection  of 
the  cow  affords  satisfactory  explanation  of  the  first  development  of  the  erup- 
tion in  the  cow  upon  the  teats  and  udder.  The  disease  is  conveyed,  as  a  rule, 
bv  recently-vaccinated  milkers.  It  explains  also,  as  stated,  the  protection  of 
vaccination  by  immunity  of  a  benign  attack,  and  completely  takes  the  ground 
from  under  the  feet  of  the  opponents  of  vaccination,  who  are  left  as  ignorant, 
but  none  the  less  dangerous,  possible  lepers  in  a  community.  Proof  of  pro- 
tection may  be  thus  written  with  the  pen,  but  it  has  come  true,  as  Jenner  said 
it  would,  that  ^'  the  keenest  of  all  arguments  for  or  against  the  practice  of 
vaccination  loill  he  those  engraved  with  the  point  of  a  knife." 

As  already  stated,  it  is  a  matter  of  indifference,  so  far  as  protection  is  con- 
cerned, whether  use  be  made  of  human  or  bovine  lymph.  Objection  was 
raised  against  human  lymph  on  the  ground  that  it  had  undergone  degradation. 
Hebra  declared,  however,  that  the  lymph  used  in  Vienna  produced  the  same 
effect  as  when  first  introduced.  Chapin  of  Rhode  Island  made  the  same 
observation  in  regard  to  matter  that  had  been  employed  for  twenty-six 
years  upon  nearly  forty-seven  thousand  persons.  With  proper  care  in  the 
selection  and  preservation  of  lymph  it  undergoes  no  diminution  in  potency 
and  powers  of  protection. 

A  valid  objection  to  the  use  of  human  lymph  is,  however,  the  possibility  of 
the  conveyance  of  other  diseases.  Thus,  it  has  been  asserted  that  tuberculosis, 
syphilis,  and  erysipelas  have  been  transmitted  in  this  way.  The  possibility 
of  introducing  these  diseases  with  vaccination  is  unquestioned,  although,  as  a 
matter  of  fact,  tuberculosis  has  never  been  transmitted  in  this  way.  The  few 
a])parent  cases  recorded  meet  with  tru^r  interpretation  as  localizations  of  bacilli 
of  tuberculosis  previously  latent  in  lymphatic  glands  (scrofula).  As  to  syphilis, 
there  is  no  doubt.  It  is  admitted  that  the  disease  has  been  introduced  in  this 
way  by  the  use  of  virus  from  syphilitic  infants.  It  was  for  a  long  time  main- 
tained that  this  disease  could  not  be  thus  conveyed  unless  blood,  pus,  or  other 
matter  than  pure  lymph  itself  had  been  introduced  with  the  lymph  itself.  It 
is,  however,  now  determined  that  the  virus  of  sy])hilis  may  be  conveyed  with 
the  pure  lymph  of  vaccinia  virus.     Robert  Cory,  chief  of  the  Natural  Vaccine 


VA  CCIX.  1  TIOX.  295 

Establishnicnt,  Enolaiul,  settled  this  question  \vith  a  soU-saerifice  that  finds 
but  too  frequent  folloMing  in  other  fields.  He  seleetcd  only  elear,  pure  lymph 
from  children  who  showed  unmistakable  evidence  of  the  disease  in  the  stage 
of  active  eruption.  With  this  lymph  he  vaccinated  himself  on  several  occa- 
sions. After  repeated  failures  he  succeeded  in  producing  ,  in  the  course  of 
three  weeks  after  a  last  nioculation,  a  distinct  eruption,  followed  in  regular 
course  by  sore  throat  and  other  unmistakable  evidence  of  syphilis  (Plant). 
The  difficulty,  as  well  as  the  possibility,  of  transmitting  syphilis  in  this  way 
is  proven  in  this  experiment.  The  smallest  precaution  as  to  the  selection  of 
subjects  suffices  to  procure  protection  against  this  disaster.  The  transmission 
of  syphilis  is  easily  avoidable  by  taking  matter  only  from  healthy  children  at 
least  six  months  old,  the  ultimate  limit  of  "tardy"  inherited  syphilis,  and  all 
possibility  is  absolutely  excluded  by  the  use  of  animal  matter,  as  syphilis  is 
an  exclusively  human  disease. 

The  streptococcus  of  erysipelas  may  be  introduced  with  vaccination  or  may 
fall  later  upon  the  broken  surface.  The  accident  is  rare  in  any  event,  occur- 
ring in  the  practice  of  the  author  but  twice  in  twenty-five  years,  but  has  been 
sufficientlv  frequent  during  the  prevalence  of  an  epidemic  of  erysipelas,  as  in 
Boston  in  1854,  to  justify  the  suspension  or  postponement  of  vaccination. 

Vaccination  should  be  done  at  the  age  of  three  to  six  months,  or,  in  the 
presence  of  an  epidemic,  at  any  time,  even  at  birth.  In  case  of  failure  the 
operation  should  be  repeated  at  intervals  untd  it  is  crowned  with  complete 
su(,'cess.  Whatever  diversity  of  opinion  may  prevail  as  to  the  iclative  value 
of  human  and  animaF  matter,  it  is  now  established  that  either  confers  relative 
immunitv  for  life,  and  absolute  immunity  for  at  least  seven  to  ten  years. 
Animal  virus,  as  stated,  takes  later  by  one  or  two  days,  and  takes  harder  as 
a  rule — /.  e.  with  more  inflammation — but  its  readier  supply  (a  single  heifer 
mav  furnish  two  thousand  to  ten  thousand  effective  ivory  or  bone  ]>oints)  and 
freedom  from  any  possible  taint  of  syphilis  soon  secured  for  it  general  adop- 
tion. Revaccination  at  stated  intervals — at  puberty,  maturity,  or  at  any  time 
during  an  epidemic — robs  the  question  of  the  vahic  of  the  kind  of  virus  ov 
the  number  of  simultaneous  vaccinations  of  practical  interest. 

Points  of  selection  for  the  operation  are  about  the  insertion  of  the  deltoid 
or  the  junction  of  the  heads  of  the  gastrocnemii  muscles.  As  a  protection 
against  future  carelessness  regarding  revaccination  the  matter  may  be  intro- 
duced in  three  places,  at  the  angles  of  a  triangk — horizontal  insertions  at  the 
shoulders  permit  concealment  by  a  narrow  sleeve — at  least  half  an  inch  distant 
from  each  other.  Six  or  eight  parallel  trafings  or  strokes,  with  as  many  cross- 
strokes,  with  the  point  of  a  knife  so  light  as  to  expose  the  superficial  lymphatics 
and  draw  little  or  no  blood,  afford  the  best  wound,  upon  which  the  moistened 
bone  surfaces  may  be  gently  rubbed. 

Susceptibility  is  universal.  There  is  no  such  thing  as  insusceptibility  to 
vaccination.  Seaton  never  saw  it  in  nioiv  than  nine  thousand  cases  at  the 
Black  Friars  National  Vaccine  Station.  Cory  confirms  this  statement  with 
reference  later  to  bovine  lynqyh,  and  I{oi)crtson  declares  that  so-called  cnnsti- 


296  VACCINATION. 

tutiunal  insusceptibility  is  usually  a  confession  on  the  part  of  the  operator  that 
he  lias  not  ascertained  the  cause  of  his  failures.  This  fact  proves  also  that 
there  is  no  real  insusceptibility  to  true  variola :  escape  is  due  to  accident. 

The  true  lesion  of  vaccination  shows  all  the  characteristics  of  a  single  typical 
small-pox  pustule.  At  the  end  of  forty-eight  hours  the  surface  of  insertion  is 
marked  by  slight  redness  and  swelling  to  the  size  of  a  large  papule,  upon  the 
summit  of  which  develops  by  the  third  or  fourth  day  a  small  vesicle  filled  with 
a  clear  fluid.  This  vesicle  is  a  reticulated  sac,  the  puncture  of  which — as  for  the 
collection  of  lymph — discharges  its  fluid  contents  by  slow  oozing.  It  reaches 
its  maximum  size  by  the  seventh  or  eighth  day,  at  which  time  it  is'umbilicated 
and  surrounded  by  a  ring  of  inflamed  tissue — the  areola — which  continues  to 
enlarge  for  two  days,  to  attain  in  full  development  a  diameter  of  one  to  three 
inches.  The  contents  of  the  vesicle  now  begin  to  grow  somewhat  opaque  (pus) 
— to  present  the  appearance  on  its  inflamed  base  quaintly  described  by  Jenner 
as  "  the  pearl  on  the  rose."  The  areola  is  the  evidence  of  a  successful  vac- 
cination. By  the  tenth  day  the  serum  is  changed  into  pus,  the  vesicle  has 
become  opaque,  and  its  centre  shows  yellow  inspissation  in  the  form  of  a  crust, 
which  by  the  fourteenth  day  extends  to  convert  the  whole  pustule  into  a  hard, 
dry  mass.  The  crust  falls  spontaneously  by  the  twentieth  to  twenty -fifth  day,  to 
leave  as  a  result  of  the  destruction  of  tissue  a  characteristic  scar.  The  cicatrix 
of  vaccinia  is  a  more  or  less  circular  depression  marked  by  minute  pits  and 
radiating  lines.  It  should  measure  in  its  diameter  fully  one-third  of  an  inch. 
Red  or  pink  at  first,  its  color  gradually  fades  to  the  bleached  appearance  of 
cicatricial  tissue,  to  remain  as  a  mark  for  life  or  to  gradually  disappear  in  the 
course  of  adolescence  to  the  faintest  trace.  However  pronounced,  a  cicatrix,  it 
is  needless  to  state,  is  evidence  only  of  destruction  of  tissue,  not  of  permanent 
protection  against  small-pox.  The  writer  recalls  a  malignant  case  of  purpura 
variolosa  in  a  young  woman  whose  arms  were  marked  by  two  typical  cica- 
trices, relics  of  successful  vaccination  in  early  childhood.  Slight  fever,  fret- 
fulness,  headache,  insomnia,  restlessness,  disturbance  of  digestion,  lymphangitis 
as  evidenced  by  swelling  of  the  axillary  glands,  may  be  present  for  a  few  days 
at  about  the  time  of  maturation  of  the  vesicle,  to  subside  rapidly  during  the 
period  of  incrustation.  More  extensive  inflammation,  dermatitis,  or  destruc- 
tion indicates  mixed  infection.  The  constitutional  signs  are  mildest  in  infancy 
and  increase  in  severity  with  advancing  years. 

Delay  in  the  appearance  of  the  vesicle  even  to  the  end  of  a  week  does  not 
])reclude  success,  provided  the  subsequent  phenomena  ap})ear  in  course.  Ac- 
celerated, abortive,  so-called  "spurious"  v'accinations  differ  in  various  ways, 
and  furnish  only  partial,  limited,  or  no  protection. 

It  is  estimated  that  at  the  present  time  twenty -two  million  people  are  vac- 
cinated every  year. 


VARICELLA. 

By  JAMES  T.  WHITTAKER. 


Varicella  or  varicellsc — diminutive  of  varus,  pimple,  pock ;  chicken- 
(French,  chiehe ;  Latin,  cicer,  insignificant)  pocks  or  pox  ;  watcr-pock,  wind- 
pox  ;  variola  notha,  spuria  ;  false  pox — is  a  trivial  acute  infection  of  childhood, 
distinguished  by  a  long  period  of  incubation,  absence  of  prodromata,  slight 
fever,  a  vesicular  eruption  varied  in  size  and  short  in  duration  ;  as  a  rule, 
without  complications  or  sequelae. 

Chicken-pox  was  first  described  under  the  term  crystalli  by  the  Italian 
anatomists — Igrassias  in  1575,  Guido  Guidi  in  1585 — and  received  its  pres- 
ent unfortunate  name  from  Vogel  in  1764, 

History. — Fuller  (1730)  and  Heberden  (1767)  made  the  first  attempts  to 
separate  this  affection  from  variola  (varioloid),  with  which  it  had  been  for- 
merly confounded,  and  has  been  so  since  by  many  authors  (Hebra,  Thompson) 
"with  inconceivable  persistence  "  (Thomas) — a  mistake  which  resulted  in  com- 
plete confusion  regarding  the  nature  of  both  affections,  and  in  reproach  and 
disrepute  of  vaccination  in  the  early  years  of  its  jiractice. 

As  early  as  1690,  Morton,  who  introduced  later  the  term  ''chicken-pox," 
is  said  to  have  described  a  case  of  varicella  under  the  title  "  variola  maxime 
benigna/'  and  Jennings  declares  tiiat  at  this  time  the  disease  was  distinguished 
by  the  people  from  small-pox.  Opposition  to  inoculation  toward  the  close  of 
the  last  century  concentrated  attention  upon  the  milder  forms  of  small-pox, 
and  the  practice  of  inoculation — which  was,  by  the  way,  a  very  lucrative  pro- 
cedure— depended  upon  the  separation  of  varioloid  and  simulating  affections. 
Willan  (1798)  discussed  the  eruption  in  detail,  describing  the  vesicles  as  acumi- 
nate, conoidal,  and  globate.  With  the  introduction  of  vaccination  it  again  be- 
c^me  necessary  in  its  defence  to  separate  cases  of  varicella,  but,  notwithstand- 
ing all  the  study  that  has  been  put  upon  these  infections,  the  difference  between 
varicella  and  varioloid  has  been  at  times  so  little  marked  as  to  have  led  cer- 
tain eminent  authorities  to  regard  them  as  identical,  or  to  look  upon  chicken- 
pox,  as  Morton  put  it,  as  the  most  benign  variola.     Kaposi  and  JJruyelle  still 

support  this  view. 

Nature  and  Etiology.— Gee  declares  that  there  is  not  u|)on  record  a  single 
authentic  instance  where  varicella  resulted  from  variohi,  or  rice  versa.  So,  too, 
epidemics  prevail  entirely  independently  of  each  other.  Mohl  emi)hasized  this 
fact  by  the  statement  that  small-pox  was  entirely  absent  in  CopcMihagcn  from 
1809  to  182.3,  while  chicken-i)ox  was  frniucnt  every  year.  Successive  ej)i- 
demics  are  very  rare  in  varicelhi,  but  very  frecineut  in  small-pox.     Tiiocnlnfed 


298 


VARICELLA. 


small-pox  produces  at  times  a  very  light  form  of  variola,  but  the  form  is  never 
so  light  but  that  it  may  be  distinguished  from  varicella.  Both  variola  and 
vaccinia  protect  against  variola,  but  not  against  varicella.  It  is  impossible  to 
conceive  of  the  occurrence  of  a  case  of  varioloid,  however  benign,  immedi- 
ately or  shortly  after  an  attack  of  small-pox  of  any  kind  or  shortly  after  a 
successful  vaccination,  but  infinite  are  the  cases  in  which  chicken-pox  has  fol- 
lowed upon  the  heels  of  variola  or  has  occurred  in  the  course  of  or  soon  after 
vaccinia.  Varicella  is  a  disease  of  childhood  almost  absolutely.  Variola  is  a 
disease  of  chilhood  by  preference,  but  does  not  spare  the  adult  unprotected  by 
previous  attack  or  by  vaccination. 

If  varicella  is  but  a  modified  variola,  there  should  be  upon  record  at  least 
one  authentic  case  of  communication  of  this  disease  to  some  adult  member  of  a 
family.  Hochsinger  thought  that  he  had  seen  such  a  case  when  a  boy,  set.  10, 
affected  with  varicella  (together  with  fourteen  of  his  school-mates),  communi- 
cated chicken-pox  to  his  brother,  ?et.  14,  who  had  not  been  at  school,  and 
small-pox  to  his  mother,  set.  40,  who  had  not  been  away  from  her  home. 
The  small-pox  case  ran  a  typical  course,  and  the  author  concluded  from  this 
observation  that  the  old  Hebra-Kaposi  doctrine  of  identity  was  thus  re-estab- 
lished. Close  study  of  these  cases  convinced  Thomas,  however,  that  they  were 
all  of  them  mild  cases  of  varioloid.  Varicella  very  rarely  attacks  a  whole 
family,  and  still  more  rarely  those  of  the  ages  mentioned.  Henoch  says  that 
he  never  saw  an  undoubted  case  in  an  adult.  It  is  known,  moreover,  that 
individuals  who  have  been  vaccinated,  or  even  revaccinated,  may,  after  a  cer- 
tain indefinite  period,  suffer  attack  of  the  lightest  possible  true  variola,  which 
may  run  its  course  without  or  with  almost  no  fever,  and  be  marked  by  an 
eruption  of  papules  or  vesicles,  but  no  pustules  at  all.  Thomas  looked  upon 
these  cases,  therefore,  as  the  very  mildest  possible  forms  of  true  small-pox, 
the  so-called  "  variola  vesiculosa." 

Inoculation  of  varicella,  when  it  succeeds,  invariably  produces  varicella, 
never  varioloid,  while  inoculation  of  varioloid  invariably  reproduces  itself 
or  variola,  and  never  varicella. 

The  study  of  the  points  of  resemblance  and  difference  of  these  two  affec- 
tions is  very  interesting,  not  only  from  the  standpoint  of  differential  diagnosis, 
but  also  because  it  tiirows  a  side  light  upon  the  all-important  relation  of  vac- 
cinia to  variola.  Bollinger  says  "  the  small-pox  which  has  been  described  in 
dogs  has  a  much  stronger  resemblance  to  varicella  than  variola."  Dogs  do 
not  contract  small-pox. 

The  recognition  of  the  fact  that  an  attack  of  one  disease  secures  future 
immunity  from  itself,  but  does  not  protect  against  the  other,  finally  led  to  a 
distinct  separation  of  the  two  affections.  Confirmation  of  this  view  was  also 
obtained  in  the  fact,  as  stated,  that  vaccinia  does  not  prevent  varicella,  nor 
varicella  vaccinia.  Czakert,  after  three  failures  in  the  ordinary  way,  suc- 
ceeded in  vaccinating  a  boy  set.  4  by  introducing  lymph  into  the  interior 
of  vesicles  during  an  attack  of  varicella. 

Varicella  appears  in  sporadic  and  endemic  (rarely  epidemic)  form,  and  epi- 


SYMPTOMS.  299 

demi(s  never  assume  the  range  nor  show  the  intervals  of  measles  and  small- 
pox. The  disease  does  not  die  out  entirely  in  large  cities,  but  assumes  some- 
what of  epidemic  proportion  once  or  twice  a  year  on  the  opening  of  schools 
and  kindergarten.  It  is  confined  exclusively  to  childhood  (exceptions  having 
been  noted  by  Heberden,  Gregory,  and  Seitz)  up  to  the  age  of  twelve,  and  is 
rare  after  ten.  The  short-lived  contagious  principle,  probably  from  the  vesi- 
cles, is  believed  to  be  inhaled  (contagium  halituosum).  Infants  are  never  born 
with  it. 

Inoculation  experiments  fail  oftener  than  they  succeed.  Thus,  Hesse  failed 
in  87  cases,  succcetled  in  causing  a  local  ernj)tion  in  17,  and  a  general  eruption 
in  9.  Steiner  claims  to  have  succeeded  eight  times  in  ten  trials,  but  was 
unable  to  propagate  the  disease  from  any  case.  Tenholdt  found  in  the  con- 
tents of  vesicles  a  micrococcus  which,  inoculated  in  man,  produced  light  red- 
ness and  swelling  like  that  of  spurious  vaccinia,  and  in  one  case  a  vesicle 
smaller  than  a  sudamen,  the  affection  remaining  local.  Pfeiffer  found  in  fresh 
vesicles  of  thirty  cases,  without  exception,  a  parasite  showing  an  anueboid 
stage,  a  cystic  stage  with  spore-formation,  and,  after  the  development  of 
numerous  spores,  a  return  to  the  amoeboid  stage.  Inoculation  with  the 
contents  of  vesicles  showed  three  times  in  five  days  a  localized,  circumscribed 
varicellar  exanthem,  recurring  in  a  scattered  manner  up  to  the  eighth  day. 
The  parasite  could  not  be  cultivated  upon  any  cidture  soil. 

Symptoms. — The  incubation  period  varies  from  eight  to  seventeen  days. 
Prodromata,  in  some  form  of  light  malaise,  occur  only  very  exceptionally. 
In  rare  cases  they  may  assume  prominence,  and  tliere  may  be  headache,  vom- 
itino-.  and  hi^h  fever.     Henoch  once  saw  a  case  begin  with  convulsions. 

The  disease  is  announced,  as  a  rule,  by  the  eruj)tion,  which  shows  itself  in 
the  form  of  spots  of  hyperremia,  in  the  centre  of  which  appear,  in  the  course 
of  a  few  hours,  distinct  but  slightly  elevated  vesicles,  which  attain  their  great- 
est circumference  in  the  course  of  from  three  to  twenty-four  hours.  The  vesicles 
contain  a  clear,  sticky  serum  of  neutral  or  alkaline  (never  acid,  as  in  sudamina) 
reaction,  which  fully  distends  the  vesicle,  an<l  which  exudes  slowly,  but  not 
wholly,  on  puncture  of  the  sac.  The  serum  shows  under  the  microscope  a  few 
pus-cells,  which,  when  exceptionally  present  in  greater  quantity,  may  make 
the  vesicles  appear  like  drops  of  wax.  In  lighter  cases,  without  halo,  the 
patient  looks  as  if  sprinkled  with  drops  of  water. 

The  eruption  shows  itself  first  upon  the  neck  and  chest  (face,  according  to 
Thomas),  to  spread  subsequently  over  the  face  and  scalp,  trunk,  and  extrem- 
ities, and  shows  itself  always  in  successive  crops,  to  the  number  of  ten  to  filty, 
or  as  many  as  two  hundred  to  eight  hundred,  over  the  whole  body,  irregularly, 
never  uniformly  or  at  once. 

The  vesicles  vary  also  in  size,  usually  from  a  i)in-head  to  a  pea,  cxcepticm- 
ally  from  a  dime  even  to  a  dollar.  These  large  vesicles  arc,  however,  always 
lax,  never  full,  as  is  the  case  in  the  blebs  of  burns,  blisters,  and  pemphigus. 
Distinct,  isolate,  and  irregular  elsewhere,  they  may  show  aggregation^  like 
zcster  upon  the  extremities,  but  are  very  rarely  confluent  at  any  part.     They 


300  VARICELLA. 

are  very  superficial,  lifting  only  the  upper  layers  of  the  epidermis,  and  pene- 
trate to  the  rete  Malpighi  in  only  exceptional  cases.  Hence  they  but  rarely 
show  an  umbilicus  and  seldom  leave  a  scar. 

A  peculiarity  of  the  eruption  may  be  its  simultaneous  appearance  in 
different  parts  of  the  body.  It  does  not  begin  definitely ;  it  does  not 
show  any  regular  grouping  or  course  in  its  progress  over  the  body.  In 
places  the  vesicles  may  stand  apart,  while  elsewhere  they  may  be  closely 
grouped.  Closer  contact  is  most  frequently  observed  in  parts  subjected  to 
pressure  or  heat,  as  on  the  back  or  about  the  tuberosities  of  the  ischia,  where 
the  eruption  may  be  grouped  to  resemble  zoster.  Decubitus  on  one  side  may 
determine  the  eruption  to  that  region.  Any  surface  of  local  hypersemia  or 
surface  subject  to  tension,  as  from  an  underlying  abscess,  may  be  thickly 
covered. 

The  eruption  is  at  first,  as  stated,  macular.  It  occurs  as  rounded  red 
spots,  like  the  rose  spots  of  typhoid  fever  (Trousseau),  in  the  centre  of 
which  appear,  unlike  the  roseola,  a  vesicle  of  about  the  size  of  a  pin's 
head.  The  vesicle  appears  so  rapidly  as  at  times  to  seem  to  form  at 
once,  or  assumes  magnitude  in  the  course  of  an  hour  or  two  sufficient  to 
soon  cover  the  base  or  hide  it,  so  that  it  is  not  surrounded  with  a  halo 
as  in  the  case  of  small-pox. 

The  eruptions  of  varicella  and  varioloid  present  morphological  differences. 
Varicella  is  a  vesicle  from  the  start :  it  does,  in  reality,  appear  as  a  macule, 
but  the  vesicle  forms  upon  its  surface  so  soon  as  to  cover  it  at  times  in  the 
course  of  an  hour  or  two,  so  that  the  macular  state,  as  a  rule,  is  not  seen  at 
all,  and  chicken-pox  is  said  to  appear  with  vesicles.  Such  rapid  change  into 
vesicles  is  never  the  case  in  small-pox.  Variola  begins  always  with  papules. 
It  also  really  begins  with  maculae,  which  become  papular  in  the  course  of  a 
few  hours  or  by  the  time  of  the  first  observation  ;  the  pa})ules  are  converted 
into  vesicles  in  the  course  of  a  few  days,  and  vesicles  grow  so  slowly  over  the 
base  as  to  be  surrounded  with  a  more  or  less  distinct  halo  of  hypersemia.  The 
vesicle  of  chicken-pox  is  a  single  sac  which  nearly  collapses  upon  puncture; 
that  of  variola  is  multilocular  and  collapses  only  partly  upon  puncture.  It 
must,  however,  be  admitted  that  occasionally  vesicles  in  chicken-pox  are  not 
so  simple — that  among  many  will  be  found  a  few  which  may  undergo  pustula- 
tion,  and  may  show  umbilicated  surfaces  and  actually  leave  cicatricial  deformi- 
ties. The  fact  must  also  be  recalled  here  that  many  cases  of  variola  are 
maxime-benigna,  that  the  eruption  may  stop  at  the  papular  stage,  and  that  it 
is  very  frecjuently  aborted  before  the  pustular  stage.  These  are  cases  which 
Thomas  calls  the  "  variolosa  vesiculosa.'' 

The  eruption  may  last  two  to  five  days,  when  the  residue  desiccates  to  leave 
a  light  pigmentation,  very  exceptionally  ulceration  (Hesse),  which  gradually 
fades  to  leave  no  trace.  Through  premature  rupture  air  may  enter  a  vesicle 
to  produce  a  condition  known  as  varicella  ventosa  or  emphysematosa  or  wind- 
pock.  Occasionally,  as  stated,  a  few  vesicles  undergo  pustular  change,  in  which 
case  they  become  opaque  by  the  end  of  the  second  day.    The  pustule  then  begins 


k 


DJA  ayosis.  301 

to  desiccate  by  tlie  third  dav,  to  collapse  later  into  a  brownish  crust  and  leave 
pigmented  reddish  spots  for  eight  to  fourteen  days.  The  crusts  disappear,  as 
a  rule,  to  leave  no  scars.  Now  and  then  a  bigger  pustule  will  have  invailed 
the  deeper  structure  of  the  skin  to  produce  a  permanent  lesion,  so  that  a  few 
well-marked  cicatrices  about  the  forehead  or  eyelids  may  cause  as  much  de- 
formity as  a  case  of  varioloid.  The  isolated,  soft,  chalk-white,  superficial  scars 
seen  upon  the  forehead,  side  of  the  face,  or  about  the  mouth  in  children  are 
generally  relics  of  varicella. 

The  eruption  of  varicella  is  irregular  in  every  regard.  It  does  not  all 
come  at  once  :  it  does  not  all  disappear  at  once.  New  groups  may  api)car  in 
irregular  succession,  and  vesiciles  may  show  themselves  in  one  part  of  the  botly 
side  by  side  with  traces  of  previous  eruption. 

The  eruption  may  also  show  itself  on  various  mucosae,  as  in  the  eves,  to 
produce  conjunctivitis  or  keratitis;  in  the  mouth  and  palate,  to  cause  stomatitis  ; 
in  the  pharynx,  to  lead  to  more  or  less  dysphagia,  and  induce,  at  times,  swell- 
ing of  the  cervical  glands ;  on  the  vulva  and  prepuce,  where  it  may  show 
itself  as  a  string  of  vesicles  on  the  inner  aspect  of  the  labia  majora;  or  at  the 
frenum,  to  give  rise  to  pain  in  micturition.  Vesicles  which  appear  in  the 
mouth,  especially  on  the  tongue,  are  readily  broken  to  show  irregular  ragged 
abrasions,  sometimes  with  aphtha-like  surfaces. 

A  slight  rise  of  temperature,  maximum  102°  F.  (exceptionally  10G°,  Ile- 
berden),  with  associated  symptoms  of  fever,  headache,  insomnia,  anorexia, 
nausea,  etc.,  attends  or  may  attend  the  eruption,  to  continue  with  it  two  or 
three,  or  exceptionally  as  long  as  five,  days.  Defervescence  is  by  crisis,  with- 
out subsequent  elevation  or  interruption.  Very  light  cases  may  show  no  fever 
at  all.     Relapses  and  recurrences  are  possible,  but  not  probable. 

Hutchinson  described  jji  grave  varicella  which  occurs  most  commonly  in 
weakly,  ill-nourished  children.  The  vesicles,  instead  of  drying  up  in  the  or- 
dinary way,  grow  blacker  and  larger,  to  present  the  appearence  of  round  l)lack 
spots,  of  the  diameter  of  an  inch  or  more,  scattered  over  the  body.  These 
crusts  cover  underlying  ulcers,  which  sometimes  extend  through  the  skin  and 
subjacent  muscular  tissue.  These  cases  are  said  to  be  very  fatal.  Tluy  may 
be  attended  with  eye  complications — irido-choroiditis  and  loss  of  sight.  This 
variety  must  be  exceedingly  rare,  as  it  is  not  mentioned  by  other  authors 
than  Eustace  Smith,  who  connects  it  with  the  curious  tendency  to  gangrene 
seen  in  certain  children.  It  is  probably  the  result  of  a  mixed  infection,  and 
has  no  more  to  do  with  genuine  varicella  than  a  coincident  erysipelas  or  other 
dermatitis.  H:emorrhagic  varicella  has  been  observed  (.Vndrew)  as  a  special 
complication  in  cachectic  cases.  Varicella  may  occur  in  connection  with  other 
infecti(»ns — with  measles,  scarlet  fever,  diphtheria,  pertussi.s,  and  even  with 
variola  (Sharkey). 

Diag-nosis. — Inasmuch  as  varicella  was  so  long,  and  is  often  yet,  mistaken 
for  variola  (varioloid),  the  question  of  dilTerenlial  diagnosis  assumes  supreme 
importance.  The  diagnosis  demands,  first,  a  knowledge  of  (he  existence  of 
either  disease  in  the  vicinity  or  comnuniity,  and  a  definite  history  of  (lie  |)re- 


302  VARICELLA. 

existence  or  absence  of  either  in  the  individual,  together  with  the  period  of 
the  last  successful  vaccination;  second,  the  age  of  the  patient,  as  variola 
occurs  at  all  ages,  and  varicella  is  almost  confined  to  childhood.  Variola  is 
preceded  by  prodromata — malaise,  fever,  headache,  backache,  sometimes  by 
initial  rashes — and  is  attended  by  a  characteristic  eruption  on  the  third  day ; 
varicella  announces  itself  by  its  eruption  without  prodromata.  The  most 
anxious  mothers  seldom  notice  illness  of  any  kind  until  the  eruption  appears. 
The  physician  is  called  to  decipher  the  eruption. 

Varicella  appears,  as  a  rule,  first  upon  the  back,  neck,  and  chest,  or,  if 
upon  the  face,  irregularly  over  it  and  irregularly  over  the  body.  Variola 
appears,  as  a  rule,  first  upon  the  face,  forehead,  to  extend  over  it  regularly 
from  above  downward,  thence  to  spread  uniformly  over  the  neck,  chest,  etc. 

The  superficial  vesicles  of  varicella  contain  only  serum ;  the  deeper-seated 
vesicles  of  variola  contain  serum,  and  later  pus. 

The  eruption  of  variola  is  much  more  uniform  in  size  ;  that  of  varicella 
varies  greatly. 

Varicella  is  rarely  confluent  anywhere,  and  its  vesicles  are  only  excep- 
tionally umbilicated.  By  the  end  of  the  third  day  spots  of  hypersemia,  fully- 
developed  vesicles,  and  crusts  may  be  perceived  simultaneously  and  side  by 
side  in  varicella,  whereas  the  variations  in  the  age  of  the  eruption  would  be 
observed  only  at  points  distant  from  each  other  in  variola. 

The  eruption  of  varicella  may  be  abundant  anywhere  over  the  body,  the 
face,  trunk,  or  extremities ;  the  eruption  of  variola  is  most  abundant  upon 
the  face  and  fingers.  A  thick  eruption  upon  the  fingers  has  often  established 
the  presence  of  variola. 

Fever  precedes  by  several  days  the  eruption  of  variola,  to  fall  with  its 
appearance,  whereas  fever  occurs  only  with  the  eruption  of  varicella,  to 
increase  with  its  development.  Variola  shows  in  its  further  course  sec- 
ondary fever,  this  being  absent  in  varicella. 

There  are  exceptions  to  all  these  rules,  but  these  form  in  their  ensemble 
almost  unimpeachable  evidence.  The  cases  about  which  may  still  hover  any 
doubt  or  uncertainty  should  be  considered  as  variola  to  secure  proper  protec- 
tion of  others  by  vaccination. 

Prophylaxis  and  Treatment. — The  mortality  of  varicella  is  practically 
iiiL  Trousseau  says  that  no  physician  has  ever  seen  a  patient  die  of  chicken-pox 
alone ;  yet,  inasmuch  as  complications,  fatal  haemorrhages,  catarrhal  pneumonia 
(Meigs  and  Pepper),  nephritis  (Hutchinson  and  Henoch),  have  been  recorded 
as  coincidences  or  complications,  delicate  children  may  be  protected  by  removal 
from  the  area  of  infection  or  isolation  of  patients  in  separate  rooms.  Patients 
should  remain  indoors,  if  not  in  bed,  during  the  existence  of  the  eruption,  and 
should  not  be  permitted  to  return  to  school  until  all  signs  of  it  have  disap- 
peared. Vesicles,  especially  when  extensive,  or  pustules  on  exposed  surfaces 
should  be  treated  with  consideration  to  prevent  or  limit  subsequent  lesion.  It 
is  advisable  to  touch  the  surface  of  such  vesicles  with  carbolic  acid  and  glycerin, 
aa,  to  secure,  if  possible,  speedy  coagulation  of  their  contents  and  destruction 


PROPHYLAXIS   AND    TREATMENT.  303 

of  pus-produeing  micro-orgauisms.  Where  the  eruption  is  unusually  abun- 
dant, as  in  the  face,  the  whole  surface  may  be  bathed  in  sublimate  solutions, 
1  : 1000-5000. 

Other  treatment  is  superfluous,  or  does  not  differ,  if  oxilled  for  by  complica- 
tions, from  that  discussed  in  considering  varioloid. 


MUMPS. 

By  JAMES  T.  WHITTAKER. 


Mumps  (from  Danish  luompen,  whence  our  words  mum,  mumble) ;  Paro- 
titis epidemica ;  Fr.  Oreillons ;  Ger.  Schafskopf,  Ziegenpeter, — is  an  acute, 
contagious  infection,  of  short  duration  and  little  gravity,  distinguished  by 
painful  inflammation  of  the  parotid  gland  and  vicinity,  sometimes  also  by 
orchitis. 

Mumps  was  known  in  the  remotest  antiquity.  Hippocrates,  mentions 
the  disease,  and  the  older  physicians  associated  it  with  measles,  scarlet  fever, 
whooping  cough,  etc.  as  an  affection  of  childhood.  It  was  observed  then,  as 
frequently  since,  that  the  disease  prevails  in  epidemic  form,  and  that  epidemics 
are  wont  to  precede  or  follow  outbreaks  of  some  of  the  exanthemata  or  other 
affections  of  childhood. 

A  special  affection  or  infection  of  the  parotid  gland  which  occurs  in  indi- 
viduals in  the  course  of,  or  as  a  sequel  to,  many  of  the  graver  infections, 
septicaemia,  typhus,  typhoid,  or  puerperal  fever,  etc.,  is  set  apart  and  distin- 
guished from  the  epidemic  parotitis  as  a  metastatic  inflammation.  A  sub- 
variety  of  this  form  may  follow  intestinal  or  pelvic  lesions.  Paget  collected 
a  number  of  cases  of  parotitis  apparently  independent  of  septic  infection — l.  e. 
imattended  with  suppuration  after  injury  or  disease  of  various  abdominal  and 
pelvic  organs 

The  older  writers,  Fourcroy  and  Portal,  attributed  the  flow  of  saliva 
which  has  been  observed  in  certain  cases  of  inflammation  of  the  pancreas  to  a 
kind  of  connection,  or  "  sympathy,"  between  the  buccal  and  so-called  abdominal 
salivary  glands.  Ca'nstatt  speaks  of  metastasis  of  mumps  to  the  pancreas  in 
the  same  sense  as  to  the  testes,  ovaries,  and  mammse,  and  Andral  and  Mondiere 
do  not  hesitate  to  declare  that  the  parotid  gland  swells  in  disease  of  the  pan- 
creas. Sehmackpfeffer  actually  reported  a  case  wherein  an  autopsy  revealed 
a  pancreatitis  in  explanation  of  a  parotitis.  In  most  of  the  cases,  however, 
inflammation  of  the  parotid  was  assumed  to  account  for  a  ptyalism  which  was 
oftener  due  to  gastric  catarrh,  or,  as  in  the  last  case  mentioned,  to  mercury 
given  for  syphilis.  Yet  after  a  full  review  of  this  subject  Friedreich  is  not 
willing  to  dismiss  the  possibility  of  such  metastasis — a  question  which  must 
be  decided  in  some  future  extensive  epidemic  of  mumps  or  fortunate  oppor- 
tunity at  autopsies. 

Etiology. — Parotitis  epidemica,  our  common  mumps,  shows  certain  pecu- 
liarities of  resemblance  to  and  difference  from  other  ordinary  infections.  There 
is,  in  the  first  place,  remarkable  predilection  for  the  colder  seasons  of  the  year. 

.304 


ETIOLOGY.  305 

Of  11 7  epidemics  tabulated  by  Hirsch,  51  occurred  in  winter,  and  of  99  studied 
by  Leichteustern,  42  were  in  the  first  quarter  of  the  year.  The  disease  shows 
also  a  preference  for  certain  localities,  in  which  it  may  prevail  continuously  or 
recur  with  every  accumulation  of  fresh  material.  Great  variation  is  shown 
also  in  its  extent  or  range.  It  remains  confined  to  certain  institutions,  board- 
ing-schools, orphan  asylums,  i>arracks,  etc.,  or,  again,  extends  over  or  is  cir- 
cumscribed to  a  certain  quarter  of  a  city,  or  ranges  over  the  entire  city  and 
surrounding  country.  Epidemics  may  be  extinguished  in  the  course  of  a  few 
weeks  or  prevail  throughout  the  greater  part  of  a  year.  The  disease  shows 
some  predilection  for  soldiers,  probably  on  account  of  close  association  in  bar- 
rack-life. Some  of  the  best  reports  are  furnished  by  the  military  surgeons 
(Bruns).  It  attacks  males  always  more  frequently  than  females,  and  is  at 
times  limited  to  children,  or,  again,  spares  no  individual  unprotected  by 
previous  attack  except  sucklings  and  old  people,  who  almost  universally 
escape.  The  age  of  preference  is  from  two  to  ten.  In  a  house  full  of  chil- 
dren mumps  usually  begins  with  the  youngest  first,  successively  seizes  the 
older  children,  and  may  afterward  attack  adults.  Ijiability  of  males  is  nearly 
universal.  The  disease  has  often  been  known  to  attack  90  per  cent,  of  the 
residents  or  inhabitants  of  public  institutions,  schools,  barracks,  etc. 

Mumps  is  undoubtedly  contagious,  and  probably,  as  no  other  explanation 
seems  possible,  through  matter  expectorated  from  the  mouth  to  contaminate 
the  atmosphere  in  the  vicinity  of  the  patient.  It  may  attack  animals  (<logs) 
with  active  salivary  glands.  Poore  declares  that  a  boy  aged  seventeen,  alfected 
with  mumps  and  five  days  later  with  inflammation  of  the  testicle,  which  suf- 
fered atrophy,  communicated  the  disease  to  a  dog,  his  constant  companion  and 
bcdfellow\  The  dog  began  to  show  symptoms  in  fourteen  days  exactly  like 
those  of  his  master,  including  subsequent  infection  of  the  testicles,  which  like- 
\vise  suffered  atrophy.  Thenceforth  the  dog  took  no  pleasure  in  the  society  of 
other  dogs,  ^vhich  he  seemed  to  shun,  and  in  his  disgust  forsook  his  old  mas- 
ter for  a  new  one.     Roth  declares  that  third  parties  may  carry  the  disease. 

Whether  mumps  be  a  general  or  local  process  is  a  question  difficult  to 
decide,  though  it  has  been  nearly  definitely  decided  in  what  way  the  poison 
of  the  disease  penetrates  to  the  parotid  gland.  With  the  older  writers  the 
view  prevailed  that  the  disease  was  a  general  infection  with  localization  in  the 
salivary  glands,  as  measles,  scarlet  fever,  and  small-pox  were  taken  to  be 
general  diseases  with  localizations  in  the  skin.  From  the  nature  of  the  dis- 
ease there  can  be  little  doubt  that  the  cause  is  a  micro-organism  which  infects 
the  blood,  or  Avhich,  from  its  nidus  in  the  parotid  gland,  evolves  toxines  ((.  pro- 
duce fever  and  the  other  general  symptoms  of  the  disease.  The  evidence  act- 
ually in  our  possession  goes  to  show  that  mumj)s  originates  in  the  mouth,  and 
not  in  the  blood — that  the  poison  of  the  disease  is  conveyed  to  the  parotid 
gland  through  the  duct  of  Steno,  and  not  llirouiih  the  blood-vessels.  This 
fact  seems  to  have  been  proven  of  metastntle  parotitis,  wli.iv  <t  priori  reasoning 
would  certainly  indicate  (leri\;ition  of  the  poison  from  the  l)lo(i(l.  What  lends 
special  support  to  this  view  in  epideniie  i)arotitis  is  the  I'aet  that  tlie  disease  la 

Vol,.  1.-20 


306  3IU3IPS. 

found  associated  almost  universally  with  stomatitis  or  some  form  of  sore  mouth 
or  sore  throat.  Ziem  thinks  that  it  is  from  the  nose,  as  he  finds  it  always  in 
connection  with,  or  as  a  sequel  to,  nasal  catarrh.  This  subject  is  discussed 
later  under  Metastatic  Parotitis. 

Soltmann  attributes  the  exemption  from  mumps  of  infancy  and  old  age  to 
the  fact  that  the  duct  of  Steno  is  too  small  in  infancy,  and  too  atrophic  in  old 
age,  to  permit  the  entrance  of  noxious  matter. 

Morbid  Anatomy. — As  the  disease  has  in  itself  no  mortality,  and  as  all 
signs  of  hyperaeraia  disappear  after  death,  study  of  the  lesion  of  mumps  is 
difficult.  It  is  rare  to  find  a  case  upon  the  post-mortem  table,  and  opportu- 
nity for  observation  may  be  furnished  only  in  cases  of  death  from  accident  or 
intercurrent  disease.  Intercurrent  disease  is  not  common.  Pure  mumps  has 
no  lesion.  Foerster  states  that  the  most  manifest  condition  is  hypersemia. 
The  gland  appears  red  on  its  cut  surface.  Serum  exudes  freely,  so  that  the 
granuhu*  aspect  is  lost.  Virchow  considers  the  affection  as  a  catarrh  of  the 
epithelial  structure.  The  succulence  imparted  to  the  gland  by  the  excessive 
iiyperfemia  and  exudation  of  serum  gives  to  it  the  doughy  feeling  different 
from  the  fluctuation  of  pus. 

These  processes  subside  entirely  with  the  process  of  resolution,  to  leave  no 
trace.  The  disease  may  extend  to  involve  also  other  salivary  glands,  the  sub- 
maxillary and  sublingual,  and  always  in  marked  cases  the  interglandular  con- 
nective tissue,  to  produce  the  distensions  and  deformities  characteristic  of 
mumps. 

Metastatic  parotitis  shows  much  graver  lesions.  Tlie  tubes  and  acini  are 
swollen  and  reddened.  There  is  the  same  extensive  infiltration  of  the  con- 
nective tissue,  but  the  disease  is  soon  distinguished  by  the  accumulation  of 
pus,  some  of  which  may  by  pressure  be  forced  out  through  the  duct  of  Steno 
into  the  mouth.  The  pus  accumulates  in  the  form  of  multiple  abscesses,  which 
break  into  each  other  to  finally  reach  the  surface  of  the  skin  or  penetrate 
deeply  into  the  tissues  of  the  throat.  Pus  may  thus  burrow  toward  the  exter- 
nal auditory  meatus  and  break  the  surface  to  discharge  from  the  external  ear, 
or  an  abscess  may  penetrate  the  anterior  mediastinum  or  force  its  M^ay  inward 
and  upward  through  the  base  of  the  skull  to  involve  the  periosteum,  attack 
the  bones,  and  reach  the  membranes  of  the  brain.  Involvement  of  the  mid- 
dle and  internal  ear,  with  destruction  of  the  bones  of  the  ear  and  lifelong  deaf- 
ness, is  a  deplorable  catastrophe  of  occasional  occurrence.  The  course  of  the 
facial  nerve  seems  especially  fitted  to  carry  infectious  matter  to  the  auditory 
api)aratus,  as  the  twigs  of  the  trifacial  favor  its  transportation  to  the  brain 
(Vogel). 

The  cause  of  mumps,  necessarily  a  micro-organism,  although  not  yet  iso- 
lated, penetrates  to  the  parotid  either  by  means  of  its  ducts  through  the  mouth 
or  through  the  blood  after  inhalation  to  the  tissues  of  the  gland.  The  first  is 
the  most  probable  mode  of  genesis,  but  whether  the  process  be  chiefly  catarrhal 
or  interstitial  is  not  yet  quite  clear.  The  contagious  principle  or  cause  of  the 
disease  finds  a  nidus  also  in  certain  cases  in  the  other  salivary  glands  and  in 


SYMPTOMS.  307 

an  organ  as  remote  as  the  testicle.  Baginsky  saw  in  the  same  family,  in  one 
boy  aged  seven  years,  the  parotid  alone  swollen,  and  in  another,  aged  ten 
months,  the  submaxillary  alone.  The  point  of  interest  in  both  cases  was  the 
tact  that  they  both  coincided  with  varicella.  Penzoldt  and  Soltmann  both 
speak  of  affection  of  the  other  salivary  glands,  and  Henoch  declares  that  he 
had  charge  of  a  case  in  which  both  submaxillary  glands  were  affcctetl  with 
subsequent  orchitis,  but  without  any  involvement  whatever  of  the  })arotids. 

One  attack  secures  future  immunity  as  a  rule. 

The  period  of  incubation  ranges  from  ten  to  fourteen  days.  It  may  be  as 
short  as  seven  or  as  long  as  twenty-one  days.  English  writers  put  it  at  a  fort- 
night, and  prove  it  by  a  fine  illustration  offered  by  Harley  :  A  medical  student 
had  mumps  in  London  at  a  time  when  his  mother  was  staying  with  him. 
Mother  and  son  remained  in  I^ondon  until  all  swelling  disappeared,  and  then 
went  a  hundred  miles  into  the  country,  home.  There  was  no  mumps  in  that 
neighborhood,  but  a  fortnight  after  the  arrival  one  of  the  children  was  taken 
with  the  disease,  and  it  afterward  successively  affected,  at  regular  intervals  of 
a  fortnight,  each  member  of  a  large  family.  The  story  is  told  as  taken  ver- 
batim from  Hooper's  Fhysician\sVade  Mecum,  7th  ed.  p.  558  (Aitken).  The 
period  of  incubation  is  usually  entirely  free  of  symptoms. 

Symptoms. — The  disease  sets  in  with  chill  or  shivering  fits,  followed  by 
fever  of  102°  to  105°  F.,  and  may  often  be  preceded  for  a  few  days  by  malaise, 
anorexia,  headache,  and  neuralgic  pains.  Coincident  with  the  elevation  of  tem- 
perature is  the  pain,  the  localization  of  which  distinguishes  the  disease.  Shoots 
and  stabs  of  pain  are  felt  at  the  angle  of  the  jaw,  radiating  to  the  temple  and 
the  ear.  The  parotid  gland  swells:  it  fills  up  the  space  between  the  mastoid 
process  and  the  angle  of  the  jaw,  mounting  over  the  side  of  the  face  and 
extending  over  the  cheek  and  down  the  neck,  with  such  a  degree  of  tume- 
faction as  at  times  to  obliterate  the  natural  outlines.  By  this  time  there  is 
such  interference  with  the  action  of  muscles  and  the  excursions  of  the  jaw 
as  to  close  it,  so  that  often  the  handle  of  a  spoon  cannot  be  inserted  between 
the  teeth.  The  pain,  on  account  of  the  tumefaction,  tension,  and  interference 
with  the  circulation,  always  severe,  is  sometimes  excruciating,  and  is  of  course 
greatly  aggravated  by  every  attempt  at  motion  of  the  jaw  and  deglutition,  or 
even  at  times  bv  the  sight  or  odor  of  food,  which  may  stimulate  the  salivary 
glands.  The  inflammation  extends  also  through  all  the  tissues  of  the  neck, 
and  is  manifest  often  in  the  throat  and  month  l)y  marked  redness  and  swelling, 
sometimes  by  actual  (lis])lacement  or  partial  occhision  of  the  palate,  j)harynx, 
and  larynx.  The  lobe  of  the  ear  is  lifted  and  carried  fi)rward.  Th(«  whole 
head  may  be  jMished  over  to  one  side.  The  swelling  readies  its  height,  as  a 
rule,  by  the  fourth  day,  when  with  the  fall  of  temperature  it  begins  to  subside, 
and  subsides  so  rai)idly  as  to  have  almost  entirely  disappeared  by  the  sixth  to 
the  eighth  dav,  nidess,  which  is  not  infreipiently  the  case,  the  oj)posite  side 
takes  on  the  same  swelling  to  repeat  the  s.niie  ])roeess.  Much  more  rarely  the 
affeetioji  is  bilateral  from  the  start.  In  >ueh  a  case  deformity  is  most  pro- 
nounced.    The  cheeks,  the  jaws,  tlie  neck  form   a  vast,  tumefied,  (edematous, 


308  MUMPS. 

indurated  mass,  and  the  suffering  from  distension  becomes  correspondingly 
great.  A  peculiar,  characteristic,  and  not  the  less  striking  because  somewhat 
comical,  picture  is  thus  presented  by  an  individual  affected  by  mumps. 

The  inflammation  or  infection  of  the  testicle  is  the  most  interesting  com- 
plication of  mumps.  The  organ  is  usually  affected  after  the  process  in  the 
parotid  has  subsided,  sometimes  coincidently,  still  more  rarely  alone  as  the 
sole  sign  of  the  infection.  It  is  the  testicle  itself  which  is  invaded  (orchitis), 
very  rarely  the  epididymis  or  the  cord,  and  then  only  after  puberty.  In 
double  mumps  the  right  testicle,  in  single  the  organ  on  the  side  of  the  affected 
parotid,  is  most  frequently  affected.  Double  orchitis  is  rare.  Affection  of  the 
testicle  is  revealed  by  a  sensation  of  weight  and  pain  in  the  gland  and  along 
the  cord,  by  fever,  and  sometimes  by  vomiting.  The  testicle  soon  becomes 
swollen  and  tender,  and  the  scrotum  is  often  reddened  and  oedematous. 
Strange  to  relate,  the  existence  of  a  gonorrhoea  during  an  attack  of  mumps 
rather  repels  than  invites  attack.  Liability  is  not  increased  by  the  severity 
of  the  mumps.     Orchitis  may  occur  in  the  lighest  case. 

Frequency  of  attack  varies  greatly.  Granier  saw  orchitis  develop  115 
times — i.  e.  23  per  cent. — in  495  cases  from  military  life,  while  Luehe  saw  it 
but  once  in  116  cases,  and  then  in  a  youth  of  sixteen  in  a  school  of  young 
cadets.  Brown  records  orchitis  10  times  after  20  cases  of  raumj)S  in  a  military 
school,  9  times  on  the  side  affected,  and  once  on  the  opposite  side,  with  subse- 
quent affection  of  the  same  side.  Homen  speaks  of  cases  of  orchitis  at  the 
early  age  of  twelve  and  fourteen,  followed  by  atrophy. 

The  process  usually  subsides  without  damage,  though  it  sometimes  results 
in  atrophy,  a  catastrophe  that  may  be  prevented  at  times  by  faradization  of 
the  testicle  on  the  subsidence  of  acute  inflammation.  Urethritis  with  blennor- 
rhoea  has  been  also  noticed  with  oedema  of  the  scrotum,  and  in  women,  very 
exceptionally,  oophoritis  with  leucorrhoea  and  swelling  of  the  external  labia 
and  the  mammary  glands. 

Mumps,  though  considered  a  light  infection,  is  liable  to  certain  very  grave 
complications.  Sadden  deafness  may  set  in  from  labyrinthine  disease,  and 
serious  affection  of  the  brain  ensue  from  interference  with  the  circulation  or 
poisoning  by  toxines. 

The  disease  may  announce  itself  with  deafness,  due  usually  to  catarrh  of 
the  middle  ear.  The  catheter  may  in  these  cases  reveal  the  presence  of  fluid 
in  the  cavity  of  the  drum,  and  inspection  disclose  hyperaemia  of  the  membrana 
tym]iani.  Meniere  and  Moure  reported  cases  of  permanent  deafness  after 
mumps,  and  Kosegarten  claimed  to  have  prevented  grave  lesion  by  the  admin- 
istration of  the  infusion  of  the  leaves  of  jaborandi.  Deafness  may  also  occur 
in  the  course  of  mumj^s  from  transmission  of  infectious  matter  to  the  labyrinth 
through  the  fissura  Glaseri  (Roosa). 

Musgrove  (Austinvillc,  Texas)  reported  in  a  very  old  lady,  aged  84,  a  case 
of  parotitis  acuta  duplex  which  ran  a  regular  course  up  to  the  sixth  day,  when 
she  suddenly  fell  into  stupor,  with  jactitation  and  stertorous  respiration.  She 
roused  from  the  stupor  sufficiently  to  swallow  fluids,  but  died  on  the  following 


METASTATIC  PA li OTITIS.  309 

day.  Percy  Smith  (London)  reported  two  cases  of  mental  alienation,  one  in  a 
yonng  merchant,  and  one  in  a  medical  stndent,  who  suffered  also  with  orchitis. 
In  the  first  case  there  set  in  after  the  eighth  day  insomnia,  which  developed  into 
acnte  mania  that  lasted  for  four  months ;  the  second  ease  develo]>ed  melancholia 
and  suicidal  mania,  which,  however,  also  entirely  disa])peared.  Botii  cases  ex- 
perienced extreme  prostration  during  the  mental  malady. 

Otiier  complications  recorded  are  hypersemia  of  the  brain  from  ]>ressure  on 
the  jugulars,  meningitis,  aml)lyo{)ia  and  color-blindness,  conjunctivitis,  laryn- 
geal stenosis,  albuminuria,  hsematuria,  nephritis.  Klichhorst  quotes  wit'.i  an 
interrogation  })oint  a  case  of  endocarditis  reported  by  Isham,  and  from  (John 
a  case  of  ursemia  and  death,  Michaelski  saw  a  death  in  convulsions.  Palsy 
of  accommodation  was  seen  once  in  an  extensive  epidemic  (Boas),  and  ])aral- 
ysis  of  the  limbs  was  reported  once  by  Joffroy.  Gowers  thinks  that  diphtheria 
may  have  been  the  disease  in  both  cases,  and  mixed  infection  migiit  account 
for  many  other  complications  mentioned.  With  all  this  list  it  must  not  be 
inferred  that  mumps  is  a  grave  disease.  The  author,  in  the  })ractice  of  a 
quarter  of  a  century,  has  never  seen  any  complication  other  than  a  trivial 
and  transitory  orchitis. 

The  diagnosis  is  usually  easy,  and  is  helped  in  any  doubt  by  the  existence 
of  the  disease  elsewhere.  The  extreme  swelling  and  pain,  with  closure  of  the 
mouth,  lifting  of  the  lobe  of  the  ear,  and  torsion  of  the  head,  distinguish  the 
affection.  Lesser  swelling  with  less  pain  may  necessitate  inspection  of  the 
throat  in  elimination  of  scarlet  fever,  diphtheria,  or  quinsy.  Digital  exam- 
ination would  detect  a  retropharyngeal  abscess,  which  might  extend  to  involve 
the  connective  tissue  about  the  jaw.  A  lymphangitis  or  simple  adenopathy 
from  infection  of  the  throat,  a  very  common  affection,  may  be  nearly  as  exten- 
sive and  painfvd  as  mumps.  It  is  usually  seated  or  arises  lower  on  the  neck, 
has  no  definite  duration,  and  is  much  more  prone  to  suppuration. 

Metastatic  Parotitis. 
Metastatic  parotitis  occurs,  as  stated,  in  connection  with,  or  in  the  course 
of,  the  more  grave  infections,  such  as  typhus,  typhoid,  and  relapsing  fever, 
yellow  fever,  pygemia,  measles,  scarlet  fever  and  small-pox,  pneumonia  and 
dvsentery.  The  disease  has  hitherto  been  regarded  strictly  as  a  metastatic 
process  due  to  transfer  of  diseased  products  from  a  distant  seat.  Recent  inves- 
tigations, however,  go  to  prove  that  the  affection  begins  in  all  cases  in  the 
mouth.  Hanau  made  a  special  study  of  the  genesis  of  five  cases  of  su|)purative 
])arotitis  which  occurred  as  a  secondary  process  in  consequence  of  sei)ti<^  infection. 
These  studies  were  made  esi)ecially  to  determine  the  question  whether  the 
disease  was  due  to  the  migration  of  the  micro-organisms  irom  the  mouth  or 
as  a  result  of  metastasis  from  the  blood.  The  micro-organisms  encountered 
wore  in  all  cases  micrococci,  which  in  their  arrangement  were  clearly  stapliy- 
lococci.  They  Avere  always  found  in  th.'  <xcn't..ry  ducts  or  in  the  abscesses 
which  had  arisen  in  connection  with  th.ni,  while  the  blood-vessels,  lymph- 
vessels,  and  acini  were  entirely  free.     Dittrich  discovered  in  fatal  suppurative 


310  JUMPS. 

parotitis  the  staphylococcus  pyogenes  aureus  as  the  sole  cause  of  the  disease. 
The  micro-organism  was  found  only  in  the  ducts,  never  in  the  vessels. 

The  process  is  thus  carried  from  the  orifices  through  the  tubes  to  the  sub- 
stance of  the  gland.  The  mouth  has  always  been  recognized  as  a  reservoir  for 
all  kinds  of  micro-organisms.  In  disease,  especially  in  fever,  conditions  accu- 
mulate to  secure  their  retention  and  multiplication,  and  the  discovery  of  this 
origin  of  parotitis  is  of  great  value  as  showing  the  necessity  of  regular  and 
thorouo-h  disinfection  of  the  mouth  in  disease  as  well  as  in  health.  It  is  of 
interest  to  note  in  this  connection  that  Testi  found  in  a  fatal  case  of  pneumonia, 
which  developed  in  its  course  unilateral  pleurisy,  multiple  abscesses  of  the 
skin,  and  a  bilateral  parotitis,  the  diplococcus  of  Friinkel  in  the  contents  of 
the  abscesses  in  the  gland.  The  finding  was  verified  by  cultivation  and 
inoculation. 

The  symptoms  of  metastatic  parotitis  do  not  differ  at  first  from  those 
already  described  of  the  more  benign  but  contagious  form  of  the  disease.  The 
gland  is  harder ;  the  inflammation  is  more  circumscribed.  The  doughy  sen- 
sation produced  by  the  intense  hyperemia  and  the  excessive  exudation  of 
serum  are  substituted  by  the  characteristic  induration  and  subsequent  fluctu- 
ation of  the  suppurative  process.  Resolution  almost  never  occurs  in  metastatic 
parotitis,  and  suppuration  shows  itself  in  the  course  of  a  few  days. 

Mumps  requires  but  little  treatment.  Confinement  to  the  house,  if  not  to 
bed,  applies  of  course  to  every  case  attended  with  fever.  Light  diet  from  ne- 
cessity, as  thin  milk,  soups,  soft-boiled  egg,  custard,  suffices  to  secure  nourish- 
ment without  strain  upon  the  inflamed  tissue  or  disturbance  of  the  stomach. 
Hot  emollient  applications,  hot  oils,  olive  oil,  cod-liver  oil,  cocoa  butter,  vase- 
line, etc.,  the  lead-and-opium  wash  bound  in  with  oiled  silk,  flannels  wrung 
out  of  hot  water,  hot,  not  too  heavy,  poultices  of  flaxseed  or  slippery  elm,  best 
relieve  the  tension  and  pain.  Gargles  of  hot  water  with  salt,  repeated  every 
half  hour  or  hour,  serve  as  poultices  applied  nearer  to  the  seat  of  the  disease. 
A  saline  laxative,  a  dose  of  calomel,  an  antipyretic,  quinine  2  to  5  grains, 
phenacetin  3  to  10  grains,  broken  doses  of  Dover's  powder  2  to  3  grains  every 
two  to  six  hours,  best  protect  the  patient  during  the  short  duration  of  the  dis- 
ease. Some  mode  of  light  suspension,  especially  in  the  recumbent  posture, 
gives  great  relief  to  a  developing  orchitis.  Faradization,  as  stated,  may  pre- 
vent atrophy.  Affections  of  the  ear  and  brain  call  for  special  treatment,  though 
little  hope  of  relief  of  a  deafness  which  sets  in  over  night  may  be  entertained. 

Metastatic  parotitis  is  treated  in  the  same  way,  with  address  to  the  remote 
origin  of  the  complication  and  speedy  evacuation  of  accumulated  pus. 


AVHOOPING  COUGH. 

By  JAMES  T.  WUITTAKKR. 


Pertussis  {per-,  intensive;  tumx,  c-ouo-h) ;  Tnssis  convulsiva ;  Gorman, 
Keuchhiisten,  Stiek-liusten,  Kinn,  Kink,  Kiml-husten  (panting,  snffbcating, 
child's  cough);  French,  Coquehiche (used  also  for  intliienza),  from  coqueluclinn, 
a  cape  worn  hv  patients;  Italian,  Tosse  asenine, — an  acute  infection  of  child- 
hood, distinguished  by  paroxysms  of  cough  in  rapid  series  threatening  suffo- 
cation, terminated  by  a  long-drawn,  audible  inspiration. 

The  name  is  derived  from  the  fact  that  the  cough  is  distinguished  b\-  a  jm-o- 
longed,  forcible,  and  audil)le  inspiration  through  a  spasmodically  contracted 
glottis.  Many  cases  of  whooping  cough,  however,  exist  without  this  character- 
istic sound,  and  where  different  stages  of  the  affection  mav  be  recoirnized  the 
sound  is  absent  during  the  whole  of  the  first  and  most  of  the  last  stage.  The 
cough  consists  of  a  series  of  short,  sharp  ex})losions,  sj)asmodic  in  their  charac- 
ter, a  series  of  ex])iratory  efforts  without  stop  to  catch  the  breath,  until  finally, 
after  the  lapse  of  from  fifteen  to  sixty  seconds,  at  the  point  of  exhaustion  occurs 
this  prolonged,  audible  inspiration.  It  is  the  series  of  explosive  coughs  in 
quick  and  uninterrupted  sequence,  the  short,  sudden  cough,  the  staccato  cougii, 
which  marks  a  case  of  whooping  cough. 

History. — The  origin  and  home  of  whooping  cough  are  involved  in 
obscurity.  According  to  Mason  Good,  the  disease  was  known  to  the  Greeks; 
but  their  descriptions,  as  Avell  as  those  of  subsequent  writers,  do  not  dis- 
tinguish it,  strange  to  say,  from  other  spasmodic  or  catarrhal  affections.  All 
authors  agree  that  the  disease  was  certainly  definitely  described  by  Jiaillon 
(Paris,  1578)  as  an  epidemic  of  a  cough  ''qui  tussis  quinta  sen  quintana  quod 
certis  horis  repetit."  Baillou  spoke  of  it  as  a  well-known  malady.  For  the 
most  part,  however,  it  was  still  confounded  with  bron(;hitis,  croup,  and  iuHu- 
enza  up  to  and  even  into  the  eighteenth  century.  Danz  published  the  first 
compilation  in  a  monograph  in  1791.  Cidlen  accurately  and  graphically 
described  the  disease  as  a  contagious  malady  attended  by  cough,  convulsive 
and  strangulating,  with  sonorous  insj)iration,  frequently  repeated,  and  oClcu 
followed  by  vomiting — ''morbus  contagiosus,  tussis  convulsiva,  slrangulans, 
cum  inspiratione  sonora,  iterata,  sa?i)e  vomitus."  By  (he  end  of  the  eightecnih 
century  reports  of  epidenu'cs  began  to  multiply.  It  seemed  to  spread  from 
different  centres  in  Kuro])e,  prevailing  with  greatest  fre(|uency  and  intensity  in 
the  colder  climates.  The  laige-t  number  of  deaths  were  re|)ort<'d  (Voin  Nor- 
way, Sweden,  and   Deuuiark,   tlion^li    In    Ireland  it    ranked,   as   it   still    ranks, 


312  WHOOPIXG    COUGH. 

fifth  among  the  causes  of  death.  By  the  end  of  the  eighteenth  and  the  begin- 
niuo-  of  the  nineteenth  century  the  disease  began  to  be  distinctly  separated 
from  allied  affections.  Thus  the  first  period  in  the  history  of  whooping  cough 
was  distinguished  by  a  more  perfect  conception  of  the  nature  of  the  disease,  a 
more  accurate  description  of  its  symptoms,  as  well  as  by  considerable  strife  as 
to  the  age  of  the  disease,  its  causes,  and,  according  to  Wunderlich,  the  recom- 
mendation of  infinite  drugs  in  its  relief.  The  lapse  of  nearly  a  century  has 
not  entirely  cleared  up  these  obscurities  as  to  nature  and  cause,  nor  relieved 
the  practice  of  medicine  of  the  odium  of  polypharmacy  in  treatment. 

Etiology. — Broussais  looked  upon  whooping  cough  as  a  variety  of  bron- 
chitis ;  Beau  regarded  it  as  a  laryngitis  ;  Copeland,  Webster,  treated  it  as  a 
neurosis ;  Friedleben  considered  it  an  effect  of  pressure  of  swollen  tracheal  or 
bronchial  glands  upon  the  vagus  nerve.  Canstatt  and  Lebert  first  jiroclaimed 
the  view  that  whooping  cough  was  a  zymotic  affection,  with  localization  in  the 
respiratory  organs.  Baginsky  calls  attention  to  the  fact  that  physiological 
experiment  demonstrates  the  superior  laryngeal  nerve  as  the  nerve  of  cough, 
and  the  regions,  the  irritation  of  which  discharge  the  most  intense  cough,  as 
the  posterior  laryngeal  wall  close  under  the  vocal  cords  and  the  bifurcation  of 
the  bronchi.  Hence,  whooping  cough  could  be  regarded  as  an  inflammation 
of  the  larynx  and  trachea. 

The  view  that  whooping  cough  depends  upon  catarrh  of  the  larynx  and 
bronchi  found  support  in  the  investigations  of  Marcus,  Loeschner,  and  0])pol- 
zer.  Herff  more  especially  had  the  almost  incredible  fortitude  to  study  the 
condition  in  himself.  Watching  his  opportunities  to  investigate  the  larynx 
even  during  an  attack,  he  found  marked  hypersemia  of  the  interarytenoid 
folds,  the  under  surface  of  the  epiglottis,  with  mucous  deposits  especially  on 
the  posterior  laryngeal  wall.  He  maintained  that  removal  of  these  deposits 
jugulated  the  attack.  Rehn  in  his  studies  found  the  posterior  wall  of  the 
larynx  perfectly  sound,  the  anterior  wall  showing  the  most  change ;  while 
Rossbach  found  all  parts  of  the  larynx  and  trachea  without  any  pathologi- 
cal alteration.  So  that  whooping  cough  has  really  no  morbid  anatomy  except 
in  its  complications. 

The  disease,  considered  first  as  an  affection  of  the  stomach,  next  as  a 
catarrh,  then  as  a  neurosis,  has  finally  taken  its  definite  place  among  the  acute 
infections.  Gerhardt  goes  so  far  as  to  remove  it  altogether  from  the  category  of 
])ulmonary  diseases  and  give  it  a  place  between  meningitis  and  cholera.  Striim- 
])('ll  discusses  it  along  with  maladies  of  the  bronchi.  Fleischer  more  properly 
])uts  it  between  croup  and  mumps.  Whooping  cough  is  certainly  an  infectious 
disease,  because  it  is  contagious  and  prevails  as  an  endemic  and  epidemic — 
because  also  of  the  absolute  immunity  which  one  attack  confers.  Rare  as  are 
second  attacks  of  scarlet  fever,  measles,  or  small-pox,  still  more  rare  are  second 
attacks  of  whooping  cough.  With  the  other  infections  it  attacks  preferably 
the  age  of  childhood.  Facts  which  have  been  taken  to  militate  against  the 
views  of  its  infectious  nature  are  absence  of  fever  and  indefiniteness  of  dura- 
tion.    Facts  which  refute  the  idea  that  pertussis  is  a  neurosis  are,  first,  origin 


ETIOLOGY.  313 

and  dissemination  by  contagion;  second,  appearance  as  an  epidemic;  third, 
immnnity  conferred  by  single  attack.  Xeuroses  belong  to  individnals  and  not 
to  numbers.  They  show  no  relation  to  others  and  have  a  constant  tendency  to 
recur. 

Proof  of  contagion  is  furnished  by  the  attack  of  wet-nurses  and  nurses 
generally,  instances  of  which  are  noticed  in  every  epidemic.  The  period  of 
preference  as  regards  age  is  from  six  months  to  six  years.  Sucklings,  because 
of  natural  immunity,  are  rarely  attacked.  Szabo  declares  that  nearly  half  of 
all  cases  occur  between  birth  and  the  age  of  two  years,  and  nearly  tiiree-fourths 
of  all  eases  between  birth  and  the  age  of  four  years.  Of  117  cases,  Baginsky 
found  but  6  over  the  age  of  four  years.  Susceptibility  diminishes  at  six  and 
is  nearly  annulled  at  ten  years,  yet  cases  are  on  record  where  the  disease  has 
occurred  in  infancy  and  advanced  life.  Barthez  and  Rilliet  observed  a  case 
of  a  newborn  child  whose  mother  had  been  attacked  four  weeks  before  its 
birth.  The  disease  set  in  on  the  day  following  birth.  Bouchut  recorded  a 
case  of  a  child  infected  on  the  second  day,  with  a  well-developed  whoop  upon 
the  eighth  day.  Berger  reported  a  case  in  a  woman  aged  fifty-seven,  ajid 
Heberden  in  a  woman  aged  seventy  and  a  man  aged  eightv.  In  the  excep- 
tional cases  in  which  the  disease  occurs  in  advanced  life  it  runs  a  mild  or 
abortive  course.  From  some  inexplicable  reason  the  female  sex  suffers  most, 
in  the  proportion,  according  to  nearly  all  authors,  of  5  to  4.  The  disease  is 
not  only  most  frequent,  but  also  more  severe,  in  girls.  Measles,  pregnancv, 
and  the  puerperium  predispose  to  pertussis.  The  contagion  is  conveved 
directly. 

The  contagious  princijde  exists  probably  in  the  sputum,  hardly,  but  possi- 
bly, in  expired  air,  which  contains  no  sputum.  It  is  nevertheless  a  contagium 
halituosum.  The  great  botanist,  Linnreus,  nearly  two  centuries  ago  expressed 
the  belief  that  whooping  cough  was  due  to  a  contagiinn  animatum  which  he 
thought  would  be  found  in  the  eggs  of  insects.  The  ])rinciple  is  thoroughly 
accepted  in  our  day.  The  cause  is  believed  to  be  a  micro-organism,  varieties 
of  which  have  been  recognized  and  described  by  Hallier,  Tjctzerich,  and  Biir- 
ger,  with  no  other  proof  of  ])athogenesis  than  presence  in  the  sputum.  Afa- 
n ass ieff  succeeded  in  isolating  from  the  sputum  of  a  whooping-cough  patient  a 
short,  thick  bacillus  which  he  cultivated  ujion  beef-jieptonc  and  agar.  The 
bacillus  differs  in  important  particidars  from  forms  hitherto  described,  and 
gives  rise,  when  introduced  into  the  trachea  or  lungs  of  dogs  and  rabbits,  to 
symptoms  simulating  whooping  cough  and  to  lobulai' j)ncumonia.  After  the 
death  of  the  animals  these  same  micro-organisms  were  discovered  in  the 
nnicous  membrane  of  the  trachea  and  bronchi,  and  also  in  the  nos(>.  As  it 
was  also  foiuid  in  the  lungs  and  bronchi  of  chihlrcn  who  had  died  of  the  dis- 
ease, the  author  considers  it  the  true  cause  of  whoo])ing  cough,  and  names  it 
the  "ba(;illus  tussis  convulsivjc."  These  investigations  were  subsequently  con- 
firmed bv  Schwenker  and  Wenat.  Ssemtchenko  after  considerable  experimen- 
tation  reached  the  following  conclusions  :  I"'irs(,  the  l)acillus  of  Afanassicff  is 
specific.     It  may  be  found   in  the  s|)n(Mni  a<  r:irly  as  the  fourth  day  of  the 


314  WHOOPING    COUGH. 

disease.  It  multiplies  in  the  body,  and  as  it  increases  the  disease  diminishes 
in  severity.  It  disappears  with  the  resolution  of  the  disease  or  when  the  par- 
oxysms are  reduced  to  two  to  four  daily.  In  the  presence  of  complications, 
especially  catarrhal  pneumonia,  it  increases  in  the  sputum.  Thus  the  bacillus 
is  of  value  not  only  in  etiology  and  diagnosis,  but  also  in  prognosis.  These 
conclusions  have,  however,  not  yet  met  with  universal  acceptance,  as  the  obser- 
vations have  not  been  sufficiently  verified.  Renewed  interest  attaches  to  this 
bacillus  of  Afanassieff  with  the  discovery  by  Griffiths  of  a  ptomaine  or  tox- 
ine  in  the  urine  of  whooi)ing-cougli  patients.  Griffiths  claims  to  have  estab- 
lished the  fact  experimentally  that  an  absolutely  identical  toxine  is  developed 
by  this-  bacillus.  The  toxine  is  not  found  in  the  urine  of  any  normal  indi- 
vidual nor  in  that  of  one  suffi3ring  from  any  disease  other  than  pertussis. 

There  is,  therefore,  scarcely  room  for  doubt  that  pertussis  is  a  mycosis 
whose  toxines  have  a  special  action  upon  that  part  of  the  nervous  system 
which  presides  over  cough — to  wit,  the  centres  of  the  superior  laryngeal  and 
vagus  nerves.  Thus  in  our  day  the  mycotic  has  displaced  the  neurotic  theory, 
and  the  views  of  Canstatt  and  Lebert  are  substantially  re-established.  Be 
this  as  it  may,  there  is  no  doubt  as  to  the  exquisite  hypersesthesia  of  the  larynx 
in  these  cases.  Any  active  movement  of  the  larynx  as  in  coughing  or  cry- 
ing, the  ingestion  of  food  and  drink,  any  irritation  as  by  exposure  to  cold  air 
as  in  a  draft  or  a  cloud  of  dust,  or  to  contaminated  air  as  in  a  close,  hot  room 
or  crowded  apartment,  any  external  pressure  or  irritation  as  by  inhalation  of 
tobacco  smoke  or  the  drinking  of  any  form  of  alcohol,  may  produce  an  explo- 
sion of  the  disease. 

The  contagious  principle  is  not  often  disseminated  without  direct  exposure 
to  the  disease.  Thus  very  slight  isolation  secures  exemption  from  attack. 
The  bacillus  has  no  great  tenacity  of  life.  Cases  in  which  the  disease  has  been 
conveyed  after  weeks  or  months  by  clothing,  curtains,  or  other  fomites,  so 
common  in  measles,  and  more  especially  in  scarlet  fever,  are  very  rare  in 
whooping  cough.  The  disease  is  spread  by  direct  contact  in  families,  and 
more  especially  in  kindergarten  and  schools,  to  assume  endemic  proportions 
and  to  cease  only  when  the  material  is  exhausted. 

Whooping  cough  occurs  with  special  frequency,  as  stated,  during  convales- 
cence from  measles.  The  disease  shows  itself  also  in  close  relation  to  tuber- 
culosis. It  has  long  been  noticed  that  tuberculosis  often  follows  close  upon  the 
heels  of  whooping  cough.  It  is  impossible  to  say  in  a  given  case  whether  the 
whooping  cough  made  the  soil  fertile  or  merely  aroused  the  latent  disease. 

Symptomatology. — The  disease  begins  with  the  signs  of  an  ordinary 
catarrh  of  the  exposed  mucous  membranes.  There  are  sometimes  conjuncti- 
vitis with  photophobia,  and  such  catarrh  of  the  nose  as  to  lead  to  the  suspicion 
of  the  development  of  measles.  Very  shortly,  if  not  simultaneously,  there  is 
bronchial  catarrh,  which  raav  distinguish  itself  in  no  way  from  an  ordinary 
cold.  The  nature  of  the  disease  may,  however,  be  anticipated,  especially  in 
the  presence  or  vicinity  of  other  cases,  on  account  of  its  severity  and  obstinacy, 
especially  on  account  of  the  undue  prostration  in  association  with  it.     Some- 


SYMPTOJfA  TOLOG  Y.  ,315 

times,  even  at  this  early  period,  there  is  a  peouliar  rintr  or  intonation  in  the 
congh  which  excites  suspicion.  Often,  again,  the  paroxysmal  nature  of  the 
outbreak  thus  early  defines  the  disease.  The  statement  of  the  mother  or 
attendant  that  the  child  coughs  worse  at  night  is  not  in  accord  with  an  ordi- 
nary catarrh.  A  simple  catarrh  of  the  larynx  or  bronchial  tubes  may  dis- 
tinguish itself  by  restlessness  and  exaggerated  cough  in  the  early  part  of  the 
night;  but  it  usually  becomes  quieter,  and  the  child  sleeps  more  or  less  con- 
tinuously after  midnight.  Whooping  cough  intrudes  itself  at  any  hour  of  the 
night,  and  rouses  the  child  usually  to  a  sitting  posture,  with  a  more  or  le&s 
violent  paroxysm.  Tlie  statement  also  that  the  cough  is  attended  with  flush- 
ing of  the  face  and  vomiting  lends  confirmation  to  suspicions.  If,  on  inspec- 
tion, the  face,  especially  the  lower  eyelids,  be  swollen  and  dusky,  the  disease 
is  probably  whooping  cough.  Throughout  the  whole  period  of  the  catarrhal 
stage,  which  lasts  from  ten  to  twelve  days,  there  is  commonly  more  or  less 
fever.  It  is  most  marked,  as  a  rule,  in  the  evening,  and  is  observed  only  in 
those  cases  where  the  temperature  is  taken  at  bed-time.  Fever  is  often  abscMit 
throughout  the  whole  course  of  the  disease. 

Whooping  cough  occurs,  as  stated,  in  paroxysms  or  explosions.  It  would 
appear  as  if  the  nerve-centres  suddenly  discharged  themselves  of  accumulated 
force  or  irritation,  as  in  a  case  of  epilepsy.  Close  observation  of  a  case  gives 
rise  to  the  impression  that  the  poison  accumulates  gradually  up  to  a  certain 
point,  when  it  may  be  no  longer  stored,  and  is  discharged  with  the  explosion 
that  characterizes  a  paroxysm  of  the  disease. 

Whooping  cough  is  usually  divided  into  three  stages — the  stages  of  catarrh, 
of  spasm,  and  of  resolution.  The  first  stage  lasts  about  one  week.  Sometimes 
this  catarrhal  stage  is  very  short,  and  the  spasmodic  element  manifests  itself 
at  the  end  of  the  second  or  third  day.  A  pseudo-crou]>  may  j>recipitate  an 
attack  at  once,  so  that  the  disease  may  supervene  on  the  day  following  the 
night  of  its  occurrence.  A  premonitory  catarrh  of  five  or  six  weeks'  duration 
is  usually  a  preceding  complication,  and  not  a  distinct  prodrome  or  stage  of 
whooping  cough. 

The  neurotic  element  now  assumes  prominence.  The  cough  becomes  more 
frecjuent,  severe,  and  harassing.  The  intervals  between  the  paroxysms  are, 
however,  more  distinct.  Very  soon  the  cough  assumes  the  convulsive  charac- 
ter mentioned,  and  sooner  or  later  occurs  the  typical  stacciito  cough,  with  the 
long-drawn,  audible  inspiration.     The  second  stage  has  now  set  in. 

In  these  attacks  the  seizure  is  sudden.  Sometimes,  though  not  as  a  ride, 
there  is  a  kind  of  premonition  or  aura  wh.ich  previous  experience  has  taught 
the  child  to  recognize.  It  is  usually  a  sense  <»f  impending  distress  or  dang<'r, 
which  leads  the  child  to  leave  its  play  and  run  to  its  parents  or  grasp  a  cliair 
for  suj)port.  A  water-closet,  a  slop-jar,  or  a  cuspidor  is  a  fre(|uent  goal.  The 
aura  may  be  in  the  form  of  dyspnnea,  prnecordial  distress,  nausea,  sometim(>s 
actual  vomiting.  Thereupon  ensiies  the  scries  of  expiratory  lonnhs  which 
distin<Miish  the  disease.  The  first  ins|)iration  is  easily  driiwn.  K\|)ira- 
tion  is  substituted  by  the  attacks  of  cough.     A   second  inspiration  is  caught 


316  WHOOPING    COUGH. 

with  difficulty,  and  is  often  interrupted  by  a  violent  spasm  of  the  glottis  and 
diaphragm.  The  child  tries  to  force  the  spasmodic  contraction.  The  face 
assumes  an  expression  of  indescribable  anxiety.  The  breath  is  lost.  The  face 
flushes  or  becomes  livid.  The  eyes  protrude.  Saliva  flows  from  the  mouth. 
The  look  is  wild,  bewildered.  There  is  for  a  few  moments  the  appearance  of 
extreme  danger.  At  last  the  expiratory  muscles  get  the  upper  hand  in  the 
form  of  a  series  of  breath-taking  coughs,  with  the  final  long-drawn,  audible 
inspiration  whereby  the  stomach  is  caught  between  the  diaphragm  and  the 
abdominal  muscles  and  its  contents  expressed  in  the  act  of  vomiting.  The 
discharge  of  the  contents  of  the  stomach  and  a  quantity  of  glassy,  glutinous 
mucus  from  the  throat  closes  the  attack.  This  scene  may,  however,  be  repeated 
once  or  twice  before  the  last  of  the  spasm  yields.  Inspiration  then  becomes 
quieter;  and  the  child,  pale,  covered  with  sweat,  exhausted,  sometimes  almost 
in  a  collapse,  is  released  until  the  next  attack.  Meanwhile  it  recovers  itself 
entirely,  resumes  its  play,  unmindful  of  the  disease,  until  it  is  suddenly  seized 
again. 

Paroxysms  occur  in  every  grade  of  severity.  They  are  sometimes  so  mild 
as  to  make  the  diagnosis  difficult,  in  other  cases  so  severe  as  to  lead  to  rupture 
of  vessels.  Haemorrhage  may  occur  from  the  nose  and  mouth.  Subconjunc- 
tival haemorrhage  is  not  uncommon.  There  are  haemorrhages  in  this  region 
which  do  not  disappear  with  the  subsidence  of  the  cough.  The  membrana 
tympani  ruptures  at  times  and  free  blood  appears  at  the  external  meatus. 
Ectatic  vessels  burst  in  the  skin  in  the  face,  in  the  cheeks,  and  show,  visible 
even  at  a  distance,  subcutaneous  extravasated  blood.  Haemorrhage  from  the 
stomach  or  intestines  or  from  the  kidneys  or  bladder  is  much  more  rare. 
Haemorrhage  in  the  brain,  which  sometimes  occurs,  is  fortunately  very  much 
more  rare.  Hernia  is  not  uncommon.  Convulsions  are  possible.  The  dura- 
tion of  an  attack  is  usually  from  half  a  minute  to  two  minutes,  though  it  seems 
to  anxious,  sympathetic  relatives  four  or  five  times  as  long. 

Paroxysms  occur  also  in  every  grade  of  frequency.  Attacks  may  be  lim- 
ited in  some  cases  to  ten  to  twelve  daily  throughout  the  whole  course  of  the 
disease,  or  they  may  occur  as  frequently  as  twenty,  forty,  or  sixty  times  in  the 
course  of  twenty-four  hours.  As  the  severity  stands  in  quite  close  relation 
with  the  frequency  of  attacks,  it  is  important  that  the  number  be  counted,  as  by 
strokes  on  a  piece  of  paper  or  a  slate,  according  to  the  suggestion  of  Trousseau. 
Diminution  in  the  number  of  attacks  is  the  first  sign  of  approaching  relief. 
During  the  interval  the  patient  is  apparently  in  a  state  of  perfect  health. 
Even  when  attacks  occur  frequently  during  the  night,  arousing  the  child  to 
a  sitting  posture  and  a  state  of  extreme  anxiety  with  the  struggle  for  air,  it 
falls  asleep  as  soon  as  the  attack  is  over,  to  become  immediately  unconscious 
of  suffering  and  to  awaken  in  the  morning  without  a  sign  of  fatigue.  Bur- 
man  attributes  the  frequency  of  attack  at  night  to  the  diminished  vigilance  of 
the  respiratory  centres,  retarded  and  more  superficial  respiration,  and  greater 
accumulation  of  carbonic  acid  gas,  which  may  at  any  time  explode  the  disease. 

About  the  fourth  decade  of  the  present  century  attention  began  to  be  direct- 


SYMPTOMATOLOGY.  317 

ed  to  the  more  or  less  constant  uppearance  of  an  nli-er  un  the  fr»nnni  lini;na\ 
The  lesion  was  observed  so  constantly  as  to  iuive  given  rise  to  the  belief  that 
it  caused  the  disease.  So  soon  as  it  was  seen  that  the  ulcer  was  absent  in 
attacks  which  occurred  in  very  early  life,  and  showed  itself  only  after  denti- 
tion, the  occurrence  of  the  lesion  was  explained  by  friction  of  the  protruded 
tongue  against  the  inferior  incisors.  More  extensive  destruction  of  tissue 
has  been  observed  also  on  the  base  of  the  tongue  by  the  side  of  the  frfenuni, 
and  a  similar  break  has  been  seen  even  upon  the  dorsum  or  upper  surface  of 
the  tongue,  where  it  has  been  protruded  against  sharp  upper  incisors.  The 
lesion  even  at  the  frsenum  is  by  no  means  universally  present.  It  is  absent 
altogether  where  the  attacks  are  very  light,  or  where  the  frwnum  is  short 
or  the  tongue  may  not  be  protruded,  or  where  the  incisors  are  dull.  It  has 
been  seen  also  independently  of  whooping  cough  in  cases  of  cough  from 
ordinary  catarrh  where  the  lower  teeth  have  been  unusuallv  incisive. 

The  spasmodic  stage  lasts,  as  a  rule,  during  two  to  four  weeks,  when  the 
interval  between  the  paroxysms  becomes  gradually  lunger  and  the  explosions 
themselves  less  severe.  A  series  of  milder  attacks  may  be  followed  by  occa- 
sional paroxysms  of  former  severity,  and  the  disease  may  be  protracted  in 
exceptional  cases  over  a  period  of  several  months.  Thus  the  period  of  reso- 
lution may  last  from  two  weeks  to  two  months.  Cases  which  are  said  to  last 
during  six  to  twelve  months  and  more  are  usually  complicated  by  chronic 
bronchitis,  bronchiectasis,  empliysema,  and  more  especially  tuberculosis.  Any 
paroxysmal  cough,  sufficiently  severe,  may  be  followed  by  an  occasional  audi- 
ble inspiration.  These  are  the  cases  in  which  the  patient  is  said  to  have  never 
recovered  from  the  disease.  Such  an  explosion  in  the  observation  of  the  author 
Mas  attributed  by  the  mother  to  an  attack  of  whooping  cough  four  years  before. 
It  was  ap{)arcntly  a  bronchiectasis. 

Whooping  cough  is  liable  to  many  complications,  especially  on  the  part 
of  the  respiratory  organs.  Bronchitis  belongs  to  the  disease,  and  usually 
drowns  all  other  sounds  in  the  lungs  with  its  rales.  Anv  disease  attended  with 
bronchitis  is  liable  also  to  broncho-pneumonia,  and  bronciio-])neumonia  i.s  the 
most  frequent  of  the  serious  comjilications  of  whooping  cough.  The  sjmsmodie 
closure  of  the  glottis  and  the  powerful  efforts  of  the  exi)iratory  nniscles  some- 
times develoj)  oedema  of  the  glottis,  more  frequently  emphysema  of  the  lungs. 
The  wonder  is  that  emphysema  is  not  more  universal.  The  occurrence  of  it 
is  in  fact  an  exception.  It  is  usually  slight,  marginal  or  perij)heral,  and  is 
niarked  bv  dilatation  only  of  the  air-cells,  whose  walls  are  so  resilient  as  to 
recover  themselves  entirely  with  the  relief  of  the  strain  on  cessation  of  the 
disease.  Sometimes,  however,  especially  in  ca^es  of  failing  nutrition,  (ubcr- 
culosis,  syphilis,  and  rickets,  the  dividing  walls  arc  broken  and  air-cells  are 
ruptured.  Still  more  rarely  air  niay  escajie  into  the  pleural  sac,  (o  <-onstitiite 
a  pneumothorax  or  l)rcak  the  lung  at  its  hilus,  rea<li  the  mediastiuum,  (ir 
escape  into  the  subcutaneous  connective  tissue  and  inllate — literally  Mow  np 
— the  u])per  half  oC  the  bodx-.  There  Is  no  better  |)rool"  of  the  -ti-ennlli  of  the 
heart  than  the  fact  that  it  escajjcs  damage  under  thopaMii  and  stasis  of  whoo))- 


318  WHOOPING    COUGH. 

iiio-  cough.  In  verv  protracted  or  extremely  severe  cases  the  heart-muscle  may 
be  finally  weakened  and  show  spots  and  regions  of  degeneration.  As  a  rule, 
however,  all  the  circulatory  disturbance  of  whooping  cough  is  limited  to  sta- 
sis and  ectatic  dilatation  of  the  vessels,  so  that  in  the  great  majority  of  cases 
nothing  is  seen  except  puffiness  of  the  eyelids  and  ectatic  vessels  about  the 
face. 

Complications  on  the  part  of  the  nervous  system  are  very  rare.  At  the 
height  of  the  attack  there  are  exjierienced  extreme  anxiety,  a  sense  of  suffocation, 
a  vertiginous  bewilderment  approaching  loss  of  consciousness,  which  disappears 
entirely  with  the  recover}^  of  the  breath.  The  momentary  apnoea  may  be  pro- 
longed to  the  point  of  danger,  and  very  young  children  may  actually  succumb 
to  suffocation.  Vomiting,  which  is  usually  hailed  with  pleasure  as  indicating 
the  end  of  the  attack,  mav  be  excessive.  It  mav  continue  into  the  interval. 
It  may  even  produce  collapse,  or  in  more  protracted  form  lead  to  marasmus. 
]Moi-e  frequently  a  more  or  less  decided  convulsion  ensues,  and  the  case  may  be 
marked  by  a  series  of  convulsions,  any  one  of  which  may  prove  fatal.  Some- 
times cerebral  symptoms  continue  during  the  interval,  and  a  case  may  bear 
the  aspect  of  a  meningitis.  Stupor,  coma,  and  hemiplegia  would  indicate  the 
occurrence  of  cerebral  haemorrhage. 

Trortzky  reported  three  cases  accompanied  by  mental  disturbance,  loss  of 
speech,  and  monoplegias.  In  one  case  a  child  aged  two  was  seized  imme- 
diately after  a  paroxysm  with  strabismus,  dilatation  of  the  pupils,  blindness, 
spasm  of  the  flexors  of  the  arm,  delirium,  and  Cheyne-Stokes  respiration.  In 
a  second  case,  in  a  boy  aged  three  and  a  half  years,  there  were  great  headache 
and  difficulty  in  thinking  and  speaking  during  the  five  weeks'  duration  of  the 
disease.     The  case  was  complicated  with  pneumonia. 

The  relation  of  pertussis  to  measles  has  been  already  remarked,  and  the 
coincidence  of  these  diseases  intensely  aggravates  the  prognosis  of  either  one. 
Pertussis  stands  also  in  close  relation  to  tuberculosis.  It  is  said  to  fertilize  the 
soil  for  the  growth  of  the  bacillus  tuberculosis.  The  truth  is  probably  that  it 
awakens  into  activity  latent  depots.  Enlarged  tracheo-bronchial  glands  have 
been  so  often  remarked  in  connection  with  pertussis  as  to  have  been  at  one 
time  considered  the  cause  of  the  disease  (Gueneau  du  Mussy).  Latent  tuber- 
culosis is  the  more  modern  explanation  of  these  adenopathies. 

The  diagnosis  of  whooping  coiigh  in  the  convulsive  stage  is  an  easy  mat- 
ter. The  series  of  rapid,  sudden,  explosive,  breath-taking  coughs,  attended  by 
the  evidence  of  venous  stasis,  cyanosis — whence  the  old  name,  blue  (!ough — 
which  ceases  only  when  a  quantity  of  mucus,  under  the  combined  efforts  of 
cough,  retching,  and  vomiting,  is  expelled  ;  the  prolonged  expiratory  efforts, 
fi)llowcd  by  a  long-drawn,  audible  inspiration,  which  has  been  not  inaptly 
likened  to  the  bray  of  an  ass;  and  the  gradual  cessation  of  the  disease, — suf- 
ficiently characterize  it. 

In  the  first  stage  whooping  cough  is  not  so  easily  separated  from  other 
forms  of  catarrhal  affections.  The  age  of  the  patient  may  throw  some  light 
upon  the  case.     The  presence  or  absence  of  the  disease  in  the  history,  more 


moayosis.  319 

esptviallv  the  existence  of  other  eases  in  the  fiimilv  or  commnnitv  :  then  the 
obstinacy  of  the  congh,  the  longer  duration,  the  fewer  physical  signs  to  account 
for  it,  the  more  spasmodic  characler  of  it,  with  intervals  of  more  complete 
exemption, — excite  suspicion  or  contirni  the  evidence  of  the  existence  of 
disease. 

In  the  last  stage  there  will  generally  have  been  a  well-marked  history  of 
previous  whoop  in  the  cough,  wiiich  may,  indeed,  be  still  occasionally  heard. 
Here,  too,  there  is  a  more  marked  interval  between  individual  attacks  tiuui  is 
common  in  the  ordinary  bronchitis  ;  a  slight  nervous  elenlent  still  prevails. 
The  cough  will  have  lasted  unusually  long,  six  to  twelve  weeks;  other  cases  ' 
in  other  stages  of  the  disease  are  in  the  vicinity,  etc. 

The  prognosis  is  for  the  most  part  entirely  favorable.  Notwithstanding 
the  threatened  suffocation  and  tremendous  strain  upon  the  heart,  recovery  is 
the  rule,  and  that  without  a  trace  of  lesion.  Complicatitins  and  bad  surroiuid- 
ings  may,  however,  intensely  aggravate  the  natural  benign  j)rognosis.  The 
prognosis  is  determined  to  a  considerable  extent  by  the  age  and  sex.  The  dis- 
ease is,  as  stated,  from  some  inexj)licable  cause,  not  only  more  frequent,  l)ut 
more  severe,  in  the  female  sex.  The  disease  becomes  less  and  less  grave  with 
advancing  life.  Maier  declares  that  97  per  cent,  of  all  the  fatal  cases  occur 
under  the  age  of  five,  58  per  cent,  in  the  first  year.  Biermer  made  a 
grand  average  of  the  established  mortality-rate,  based  upon  the  statistics 
of  many  authors,  at  7.6  per  cent. — a  figure  that  certainly  entitles  the  disease 
to  respect. 

It  is  an  error  to  consider  whooping  cough  as  a  trivial  malady.  There 
occurred  in  England  in  one  year,  of  500,341  deaths,  10,318  deaths  from 
whooping  cough.  In  New  York  in  one  decade,  wherein  4062  deaths  occurred 
from  typhoid  fever,  there  were  4094  deaths  from  whooi)ing  cough.  Ilagen- 
bach  savs  that  whooping  cough  had  more  victims  in  Basle  in  fifty  years  than 
anv  disease  except  typhoid  fever  and  dijihtheria.  The  general  mortality  is 
estimated,  as  stated,  at  3  to  7  per  cent.  It  has  reached  as  high  as  48  jjcr 
cent,  in  the  second  year  of  life. 

The  most  frequent  causes  of  death  are  (1)  suffocation  from  spasm  of  the 
glottis;  (2)  broncho-pneumonia ;  (3)  hfemorrhage ;  (4)  marasnuis.  A  simple 
peripheral  emphysema  disappears,  as  stated,  without  trace.  Interstitial,  medi- 
astinal, and  general  emphysema,  pneumothorax,  make  the  ])rognosis  grave. 

The  prognosis  depends,  aside  from  the  condition  of  the  ])atient  himself, 
ujKHi  the  severity  and  frequency  of  the  attacks.  A  single  explosion  may  last 
from  fifteen  seconds  to  an  entire  minute,  a!id  a  scries  of  explosions  which  con- 
stitute an  individual  attack  may  last  from  t<'n  to  fifteen  minutes.  The  prog- 
nosis is  grave  where  the  attacks  reach  fifty  in  the  course  of  twenty-four  hours  ; 
at  sixty  it  assumes  special  gravity.  Individual  attacks  may  <]o  damage  also 
bv  their  intensity  ;  thus  hicmorrhage  may  be  copi<.u<  rinm  mncons  surfaces. 
Blindness  occasionally  results,  prol)al)ly  from  o'dem;!  dt'  tli<'  brain.  Il  is 
almost  always  temporary,  and  disajipears  with  th'-  -nl.~i(leii<v  of  (edema.  Then 
subarachnoid  lucmorrhage,  umisual  as  it  is,  is  sometimes  liitai.    Such  excessive 


320  WHOOPING    COUGH. 

vomiting  occurs  in  certain  cases  as  may  not  be  stilled  with  the  cessation  of 
the  attack,  so  that  inanition  may  result.  Psychopathies  from  the  profound 
mental  disturbance,  fortunately,  usually  temporary,  are  occasionally  reported. 
Absolute  exophthalmos  has  been  produced  by  excessive  retro-bulbar  haemor- 
rhage. Rupture  of  the  membrana  tympani,  with  subsequent  otitis  media,  has 
resulted  in  deafness  and,  occurring  in  very  early  life,  in  deaf-mutism.  The 
frequency  with  which  the  disease  is  attended  with,  preceded  by,  or  followed  by 
tuberculosis  has  been  remarked  already.  Thus  it  will  be  seen  that  whooping 
coug-h  is  by  no  means  a  trivial  affection. 

Prophylaxis. — As  the  disease  has,  al,  least  at  times,  such  gravity,  prophy- 
laxis assumes  importance.  The  only  prophylaxis  worthy  of  the  name  is  iso- 
lation. Isolation  to  be  effective  must  be  complete.  The  patient  must  be  sep- 
arated not  only  from  children,  but  from  adults  who  come  in  contact  with  unaf- 
fected members  of  the  family.  As  this  isolation  in  a  disease  which  is  usually 
considered  so  mild  is  practically  impossible,  attention  shoidd  be  directed  rather 
to  the  protection  of  delicate  members  of  the  family ;  they  should  be  isolated 
rather  than  the  patient.  It  is  advisable  that  tuberculous,  rachitic,  syphilitic, 
or  otherwise  diseased  or  debilitated  children  should  be  removed  from  the  house 
as  early  as  possible.  AVhooping  cough  is  contagious  in  all  stages  of  the  dis- 
ease. So  long  as  there  is  cough,  matter  is  expectorated,  to  be  dried  and  dis- 
seminated, and  thus  to  convey  the  disease.  In  the  removal  of  children  from 
the  house,  warning  should  be  entered  at  the  new  place  of  residence,  that  the 
disease  may  not  be  developed  in  new  centres. 

The  most  essential  element  in  prophylaxis  at  all  times  is  the  destruction 
of  the  sputum.  Though  the  individual  is  attacked  with  the  suddeness  of  an 
explosion,  mucus,  at  least  in  quantities,  is  not  expelled  until  the  attack  has 
spent  itself,  so  that  there  is,  for  the  most  part,  time  for  the  collection  of 
sputum  in  water.  As  in  tuberculosis,  the  handkerchief  should  never  be 
used  for  the  reception  of  sputum.  Perfect  prophylaxis  implies  also  the  use 
of  separate  beds,  the  separate  washing  of  bed-linen  or  the  subjection  of  it  to 
steam  or  dry  heat,  the  use  of  separate  utensils  for  food,  the  use  of  separate 
clothing,  etc. 

Treatment. — Until  the  specific  nature  of  the  disease  shall  have  been  deter- 
mined there  can  be  no  question  of  any  specific  treatment,  and  remedies  may  be 
addressed  only  to  its  symptoms.  The  symptom  which  assumes  prominence, 
and  upon  which  nearly  all  the  complications  of  the  disease  depend,  is  the 
cough,  and  the  nature  of  the  remedy  which  is  used  against  the  cough  will 
depend  upon  the  view  which  the  practitioner  may  take  of  the  nature  of  the 
disease ;  that  is,  whether  it  be  catarrhal,  neurotic,  or  mycotic.  The  truth  is, 
the  treatment  of  whooping  cough  remains  still  in  the  stage  of  empiricism, 
and  as  nearly  every  remedy  in  the  materia  medica  has  been  tried  to  relieve 
the  cough,  so  appeal  is  made  to  every  new  remedy. 

The  older  writers  used  the  anodynes  early.  Opium  in  some  form  or  other 
was  the  shield  which  was  soon  interposed.  In  modern  times  the  active  prin- 
ciple of  opium,  morphine,  was  and  is  still  extensively  employed  : 


TREA  TMENT.  321 

i^i.  Morphlnfc  sulphatis,  gr.  ss-j  ; 

Aquse  amygdalie  amar.,  f'sss  ; 

Aquae,  f'sis.s. — M. 

Sig.  A  teaspoonful  every  two  to  six  hours. 

With  the  morphine  was  often  combined  5-  to  10-grain  doses  of  the  bro- 
mide of  sodium  or  potassium,  or  there  may  be  added  to  the  prescription  the 
hydrochlorate  of  apomorphine,  ^  grain  to  1^  grains,  or  for  the  bitter-almond 
water  or  cherry-laurel  water  may  be  substituted  \  an  ounce  of  either  glycerin 
or  syrup,  simple  or  of  orange-peel,  raspberry,  etc.  The  remedies  commonly 
employed  in  the  treatment  of  bronchitis  are  also  frequently  resorted  to.  The 
syrup,  simple  or  compound,  of  ipecac,  \  to  I  teaspoonful ;  the  wine  of  ipecac 
in  half  these  doses  ;  minute  doses  of  tartar  emetic,  ^  to  -^  of  a  grain  ;  bella- 
donna, 1  drop  of  the  tincture  for  each  year  of  life;  or  atropine,  1  grain  to 
1  ounce  of  water,  given  in  doses  of  from  1  to  2  drops  two  or  three  times  a 
day.  The  iodide  of  potassium  is  a  remedy  of  value.  It  mav  be  given  as 
follows : 

I^.  Potass,  iodi,  gss  ; 

Aquse  menth.  piperit.,  fsss. — M. 

Sig.  Two  to  five  drops  in  a  dessertspoonful  of  milk  three  or  tour  times  a  day. 

The  iodides  are  more  used  in  cases  in  which  the  chest  is  full  of  rales ;  the 
ipecac  preparations  especially  in  the  presence  of  burning  irritation  in  the  throat 
and  chest;  belladonna,  the  bromides,  and  morphine  being  addressed  more  espe- 
cially to  the  spasmodic  element. 

Camphor,  valerian,  asafoetida,  and  musk  have  their  advocates  in  the  treat- 
ment of  whooping  cough.  Chloral  had  at  one  time  high  laudation  in  doses  of 
3  to  10  grains.  Chloroform,  ether,  the  bromide  and  iodide  of  ethyl,  and  amyl 
nitrite  (2  to  5  drops)  were  inhaled  with  the  hope  of  curtailing  the  attack  ;  crc- 
asote,  the  salicylates,  and  carbolic  acid  were  remedies  administered  internally 
and  by  inhalation  for  the  destruction  of  the  assumed  mycosis.  Various  anti- 
pyretics, more  especially  antipyrine,  in  doses  of  from  2  to  5  grains  every  two 
to  four  hours,  do  certainly  prolong  the  intervals  and  mitigate  the  severity  of 
the  attack.  These  remedies  were  recommended  indeed  as  specifics  a  few  years 
ago,  with  the  later  fate  of  all  the  s})ccifics,  in  the  treatment  (if  whooping 
cough.  Saturation  with  bromides,  gr.  x-xv  four  times  a  day,  is  a  |)l:in  now 
much  in  vogue. 

The  mere  mention  of  the  names  of  remedies  recommended  from  time  to 
time  in  the  treatment  of  whooping  cough  would  consume  the  sjiace  allotted  to 
the  discussion  of  the  whole  subject.  One  remedy,  however,  deserves  mention, 
if  only  because  it  is  the  last  used.  This  is  bromoionii,  which  was  recom- 
mended first  by  Stepp  of  Niiremburg,  Lowenthal  used  it  in  Senator's  poly- 
clinic in  100  cases,  claiming  that  it  made  the  allaeks  mlMer  in  the  course  of  a 
few  days.  Bromoform  is  given  in  (hdp  doses,  2  to  5,  three  or  foni-  times  a  <l:i\ . 
Children  one  year  of  age  receive  three  times  <laily  2  to  I  (b-ops  ;  ehildren  IVuni 

Vor-  I.— 21 


322  WHOOPING    COUGH. 

two  to  four  years  of  age  receive  3  to  4  drops  three  to  four  times  daily  ;  chil- 
dren from  four  to  eight  should  receive  three  or  four  times  daily  4  to  5  drops, 
according  to  the  number  and  frequency  of  the  attacks.  The  remedy  must  be 
protected  from  the  light,  hence  in  dark  bottles  with  good  stoppers.  It  is 
usually  given  dropped  in  water,  when  care  must  be  taken  that  the  pearly 
drops  floating  about  in  the  water  are  swallowed.  If  the  use  of  the  drug  be 
stopped  too  soon,  relapses  occur.  Bad  effects  have  been  observed,  but  never 
from  these  small  doses.  One  child  which  received  a  larger  dose  than  had  been 
prescribed  fell  into  narcosis,  but  was  readily  revived.  Fischer  of  New  York 
reports  51  cases,  claiming  almost  specific  properties.  The  duration  of  the 
treatment  was  from  ten  to  thirty  days,  and  cure  occurred  in  75  per  cent,  of 
the  cases  in  from  two  to  three  weeks,  if  there  were  no  complications.  Neu- 
mann of  Berlin  is  more  temperate  in  his  statements.  He  tried  the  remedy  in 
25  cases,  and  believed  that  it  exerted  a  favorable  influence  upon  the  individ- 
ual attacks,  but  Had  no  real  effect  upon  the  course  or  duration  of  the  disease. 
He  was  never  able  to  cut  an  attack  short  even  by  early  administration  of  the 
drug,  though  he  never  saw  any  ill  effects.  These  conclusions  represent  the 
results  which  are  generally  admitted,  so  that  it  may  be  said  that  bromoform 
is  the  most  valuable  of  the  late  contributions  to  the  therapy  of  this 
disease. 

Among  the  latest  remedies  recommended  the  following  may  be  cited  :  Car- 
bolic acid  in  aqueous  solution,  1  :  120,  of  which  J  an  ounce  three  or  four  times 
a  day  is  advocated  by  Oltramare ;  hyoscine  hydriodate,  by  Edelfsen  ;  turpen- 
tine, revived  by  Ringk ;  pilocarpine  to  abort  the  disease,  by  Albrecht;  chlo- 
ride of  gold  and  sodium,  by  Magruder ;  cocaine,  by  Krimke;  peroxide  of 
hydrogen,  by  Richardson  ;  cyanide  of  mercury,  by  Drzewiecki ;  resorcin,  by 
Concetti ;  oubain,  by  Gemmel ;  thyme,  by  Johnson.  Among  remedies  to  be 
inhaled,  turpentine,  thymol,  illuminating  gas  (carburetted  hydrogen),  carbolic 
acid,  cocaine,  sulphuretted  hydrogen,  tar,  benzole,  Ledolier  recommends 
chloral  by  rectal  injection ;  Goldsmith  sprays  the  nose  with  mercuric  chlo- 
ride or  salicylates;  and  Rossbach  applies  the  constant  current  of  electricity. 

Vomiting  may  be  usually  relieved  by  chloral,  grains  2  to  5,  with  pepper- 
mint-water, a  dessertspoonful  to  a  tablespoonful,  by  the  mouth  or  if  necessary 
by  the  rectum. 

Local  applications  addressed  to  the  mycotic  nature  of  the  disease  cannot 
reach  it,  for  the  reason,  probably,  that  the  mycosis  is  in  the  blood,  and  the 
symptoms  are  due  to  toxines.  Applications  and  inhalations  of  carbolic  acid, 
chloroform,  benzine,  turpentine,  quinine,  resorcin,  however  highly  lauded  by 
individual  observers,  have  all  fallen  into  disuse.  May  it  be  mentioned  that 
Naegeli  reports  that  in  two  children  he  has  succeeded  more  than  five  hundred 
times  in  aj)parently  arresting  the  spasms  of  pertussis  by  pulling  the  lower  jaw 
downward  and  forward? 

Cocaine  has  been  tried,  but  met  with  no  better  success.  The  influence  of 
the  drug  is  too  temporary  and  its  cumulative  effects  too  depressing,  if  not 
dangerous,  to  warrant  its  continued  use,  so  that  at  the  present  time  the  treat- 


TEE  A  TMENT.  32:5 

ment  of  whooping  oough,  awaiting  the  discovery  of  some  speeifie  antitoxine, 
resolves  itself  into  the  extremely  cautions  use  of  morphine  as  a  shield  against 
the  damage  of  the  disease.  Mild  cases  are  let  alone,  on  the  principle  ^^  pvi- 
vrum  non  nocere.'^  Let  it  be  said,  for  the  honor  of  medicine  in  this  dearth 
of  therapy,  that  change  of  climate  does  often  really  "  act   like  magic." 


SEPTICEMIA  AND  PYEMIA. 

By  WILLIAM  PEPPER. 


From  the  earliest  times  the  occurrence  of  febrile  disturbance  after  wounds 
and  in  connection  with  internal  supj)uration  has  been  noted.  The  terms 
"septicaemia"  and  "pyaemia"  were  for  a  long  time  indiscriminately  used 
to  designate  the  conditions  referred  to,  and  it  is  only  since  the  development 
of  the  science  of  bacteriology  that  the  ultimate  etiological  differences  between 
the  two  conditions  have  been  satisfactorily  discovered.  While  they  come  under 
the  notice  of  the  surgeon  more  frequently  than  that  of  the  physician,  there  are 
forms  of  both  conditions  that  are  seen  by  the  latter  and  that  arise  independ- 
ently of  the  occurrence  of  external  wounds. 

Septicemia. 

Definition. — A  condition  caused  by  the  absorption  of  animal  poisons 
developed  in  the  body,  as  a  rule  due  to  bacterial  growth,  characterized  clinically 
by  febrile  reaction  and  various  accompanying  symptoms ;  pathologically,  by 
the  absence  of  purulent  fo(d  in  the  various  organs  of  the  body. 

After  the  receipt  of  any  wound  there  may  arise  a  reactionary  fever, 
whether  the  solution  of  continuity  be  exposed  to  the  air  or  enclosed  by  the 
uninjured  parts  surrounding  the  lesion.  After  simple  fractures  there  is  apt  to 
be  a  rise  of  temperature,  of  short  duration,  and  acquiring  a  Variable,  but  not 
frequently  a  considerable,  height.  This  reactionary  fever  was  at  one  time  suji- 
posed  to  be  due  to  reflex  causes,  but  it  is  more  reasonable  to  suppose  that  it  is 
produced  by  the  absorption  into  the  blood  of  some  of  the  materials  surround- 
ing the  lesion.  This  is  well  seen  in  the  febrile  condition  that  often  results 
from  the  presence  of  an  extravasation  of  blood  into  the  tissues.  In  this  form 
of  septicaemia  the  presence  of  bacteria  in  the  primary  focus  is  not  neces- 
sary. Usually  without  preceding  chill  there  is  a  ra{)id  rise  of  temperature  to 
102°,  or  even  104°  F.,  with  corresponding  rapidity  of  the  pulse,  but  without 
marked  constitutional  disturbance.  This  fever  continues  for  a  short  but 
variable  length  of  time,  from  one  to  three  or  four  days,  disappearing  spon- 
taneously and  leaving  no  sequelae.  A  second  form  may  result  from  the 
absorption  from  wounds  of  the  products  of  growth  of  the  micro-organisms 
of  putrefaction.  This  is  exemplified  in  the  rise  of  temperature  with  consti- 
tutional disturbance  seen  after  operation,  where  there  is  in  the  wound  either  a 
disorganized  blood-clot  or  a  portion  of  necrotic  tissue.  The  symptoms  in  this 
form  appear  rapidly,  and  differ  from  those  observed  in  the  form  first  described 
merely  in  their  greater  intensity  and  more  prolonged  duration.  Rapid  disap- 
pearance of  all  unfavorable  symptoms  follows  the  removal  of  the  cause. 

324 


SEPTICEMIA.  325 

In  a  third  and  more  severe  form  the  symptoms  are  produced  by  the 
absorption  of  ptomaines  from  a  local  lesion,  and  by  the  ptomaines  in  the  cir- 
culating blood  likewise  produced  by  absorbed  micro-organisms.  The  micro- 
organisms concerned  in  this  form  are  usually  the  pyogenic  micrococci.  The 
condition  is  well  seen  in  the  results  of  such  poisoned  wounds  as  are  frequently 
produced  in  the  dissecting-room.  After  a  variable  period,  twenty-four  houi-s 
to  three  or  four  days,  there  appears  a  feeling  of  malaise,  with  slight  chilly  sen- 
sations or  even  a  pronounce<l  rigor.  Soon  the  bodily  temperature  progressively 
rises,  and  shows  daily  remissions  or  intermissions.  With  this  rise  of  tempera- 
ture there  are  headache  of  variable  intensity,  loss  of  appetite,  a  moderate 
amount  of  thirst,  in  some  cases  diarrhoea.  The  pulse  is  rapid,  and  at  first  full 
and  bounding,  but  later  becomes  soft  and  compressible.  The  tongue  is  lightly 
coated  in  the  beginning,  but  as  the  bodily  temperature  rises  becomes  thickly 
coated  and  dry.  Locallv,  there  mav  be  intense  redness  and  swellino-  of  the 
part  affected  if  on  the  cutaneous  surface,  and  lymphangitis  and  lymphadenitis 
may  be  found  in  the  lymphatic  structures  that  drain  the  j)art.  If  the  cause 
be  not  removed  or  if  the  poisoning  be  very  intense,  the  patient  sinks  into 
a  typhoid  condition,  with  marked  irregular  elevation  of  temperature,  rapid, 
feeble  pulse,  delirium  of  variable  intensity,  but  usually  of  muttering  charac- 
ter, and  marked  prostration  of  all  vital  power.  The  tongue  now  is  apt  to 
become  dry  and  glazed,  or  may  be  covered,  as  are  the  teeth,  with  brownish 
sordes,  with  which  may  be  mingled  bloody  crusts  from  the  numerous  fissures 
that  are  present  in  the  organ.  If  the  condition  persist,  the  first  sound  of  the 
heart  becomes  weak,  bed-sores  form,  and  the  patient  dies  exhausted.  In  some 
cases  there  appear  before  death  petechial  spots  on  the  surface  or  hemorrhage 
mav  occur  from  various  mucous  surfaces. 

Upon  examination  after  death  there  are  no  characteristic  lesions  to  be  dis- 
covered. The  blood  is  usually  dark  in  color.  Upon  the  serous  surfaces 
points  of  extravasated  blood  may  be  seen,  or  there  may  be  found  hemorrhagic 
effusion  in  the  cavities  enclosed  by  them.  The  spleen  is  usually  enlarged  and 
softened.  The  liver  may  show  evidences  of  fatty  degeneration  or  may  be 
merely  fuller  of  blood  than  is  normal.  The*  lungs  are  apt  to  be  congested, 
chiefly  in  the  posterior  portions.  There  may  be  areas  of  atelectasis  or  of 
broncho-pneumonia.  The  heart  is  softened,  and  its  cavities  contain  either 
adherent  ante-mortem  coagula  or  grumous,  friable  post-mortem  clots.  There 
are  no  hemorrhagic  infarcts  or  metastatic  deposits  of  j>us.  Upon  micro- 
scopic examination  of  various  organs  there  may  be  found  islets  of  coagula- 
tion-necrosis. 

The  diagnosis  is,  as  a  rule,  easy,  the  only  difficulty  being  the  discovery 
of  the  source  of  blood-contamination.  By  careful  ex.lmination  into  the  his- 
tory of  the  case  this  can  usually  be  discovered  even  in  the  cases  that  do  not 
restdt  from  some  recent  injury  or  ojx'ration.  One  point  should,  however,  l>c 
borne  in  mind:  the  frequent  dependence  of  this  nmdition  upon  the  attempt 
to  i)roduce  criminal  abortion  or  upon  the  |.rescncc  in  the  uterus  of  placental 
renjains  after  an  unrecx)gni7X'd  miscarriage. 


326  SEPTICEMIA    AND    PYE3IIA. 

The  prognosis  is  in  all  cases  to  be  guarded.  Death  may  occur  within  the 
first  twentv-tbur  hours  if  the  amount  of  poison  absorbed  be  very  large. 

In  reo-ard  to  treatment  but  little  can  be  said.  Removal  of  the  cause  is  of 
the  greatest  importance.  In  addition  to  the  adoption  of  appropriate  surgical 
measures  the  patient's  strength  must  be  supported  by  appropriate  diet  and  the 
judicious  use  of  stimulants.  In  the  lighter  forms  quinine  may  be  of  value  in 
small  tonic  doses ;  in  the  more  severe  forms  its  value  is  very  slight.  The  diet 
should  consist  of  liquid,  easily  digestible  and  nourishing  articles,  such  as 
milk,  raw  or  lightly  boiled  eggs,  beef-  or  clam-juice,  and  liquid  peptonoids. 
Alcoholic  stimulants  in  some  form  are  required  in  all  severe  cases.  Careful 
attention  must  be  directed  to  the  condition  of  the  skin,  and  the  urinary  blad- 
der must  be  carefully  protected  from  over-distension.  Should  danger  arise 
from  hyperpyrexia,  suitable  hydrotherapeutic  measures  should  be  adopted. 

Pyemia. 

Definition. — A  condition  arising  from  the  diffusion  of  the  micro-organisms 
of  suppuration  throughout  the  body,  characterized  clinically  by  frequently  recur- 
ring chills,  remittent  or  intermittent  fever,  profuse  sweatings,  and  various 
symptoms  depending  upon  the  involvement  of  different  organs  ;  pathologically, 
by  the  presence  in  various  tissues  of  multiple  metastatic  purulent  foci,  pro- 
duced by  the  transference  of  the  pyogenic  micro-organisms  from  a  primary- 
focus  of  suppuration. 

As  will  be  seen  by  the  definition  given,  this  condition  is  dependent  upon 
the  presence  in  the  various  organs  of  single  or  multiple  abscesses  that  have 
been  produced  by  the  transportation  of  pyogenic  bacteria  from  some  primary 
focus,  thereby  differing  from  septicaemia,  wherein  no  such  metastasis  is  present. 
Among  the  more  frequent  sites  for  these  primary  abscesses,  when  not  traumatic, 
may  be  mentioned  the  subcutaneous  cellular  tissue  ;  the  pelvic  cellular  tissue 
and  organs;  the  subperitoneal  connective  tissue;  the  marrow  of  the  long  bones; 
the  parts  surrounding  the  middle-ear  cavity ;  and  the  joints.  It  frequently 
hapi^ens  that  wide  dissemination  of  purulent  emboli  occurs  from  an  ulcerat- 
ing lesion  of  the  cardiac  valves.  This  form  of  endocarditis  is  usually  itself 
secondary  to  some  other  lesion,  the  valves  merely  offering  a  good  breeding- 
])lace  from  which  the  bacterial  masses  may  be  swept  off  by  the  blood-stream 
and  scattered  throughout  the  body.  "  Idiopathic  pyaemia  "  is  the  name  applied 
to  those  examples  where  no  primary  purulent  focus  can  be  demonstrated. 

The  essential  cause  of  the  condition  is  one  of  the  forms  of  pyogenic 
micrococci.  The  streptococcus  pyogenes  is  the  most  frequent  form  found, 
but  the  staphylococcus  pyogenes  aureus  or  albus  is  present  in  many  instances. 
These  micro-organisms," either  by  their  own  a(!tivity  or  by  means  of  the  mate- 
rials they  produce,  cause  coagulation-necrosis  of  the  surrounding  tissue-cells  ;  by 
their  continued  action  this  area  of  coagulation-necrosis  extends;  inflammation 
of  the  veins  of  the  part  follows,  with  a  similar  process  in  the  wall  of  the  ves- 
sel ;  the  endothelium  of  the  vein  so  affected  is  loosened  from  its  dee])  attach- 
ment, and  with  its  contained  micrococci  is  swept  off  by  the  blood-stream. 


PV.EMIA.  327 

Arriving  at  some  portion  ot"  the  eireulatory  system  where  the  ealibre  ot"  tlie 
vessel  diminishes  to  such  an  extent  as  to  preehule  the  passage  of  the  embohis, 
stasis  occurs,  and,  if  the  soil  be  suitable,  the  transp<»rte(l  micrococci  repeat  tiie 
process  of  pus-formation  in  their  new  quarters.  In  this  way  are  tbrmed  nimi- 
erous  abscesses  in  various  parts  of  an  organ  or  in  various  ami  frequently 
widelv-separatetl  regions  of  the  boily.  If  the  original  foi-us  were  in  the 
superficial  portions  of  the  body  or  in  the  long  bones,  the  secondaiy  abscess 
will  be  found  in  the  lungs,  or  if  they  pass  through  these  organs  without  Uxlg- 
raent  the  heart  and  kidneys  will  offer  a  favorable  site  for  their  development. 
If  the  primary  focus  be  in  the  area  drained  by  the  portal  system,  purulent 
pylephlebitis  and  secondary  abscesses  in  the  liver  will  result.  When  malig- 
nant endocarditis  has  been  the  starting-point  of  the  emboli,  the  secondary 
foci  may  be  found  in  the  spleen,  kidneys,  brain,  skin,  or  intestines. 

The  symptoms  of  pyaemia  vary  greatly  in  different  cases,  depending  upon 
the  or^an  or  organs  that  are  the  seat  of  the  secondarv  abscesses.  There  are, 
however,  certain  syiuptoms  that  are  present  in  all  forms,  and  that  characterize 
the  condition.  The  onset  of  pysemia  is  usually  announced  by  the  occurrence 
of  a  rapid  rise  in  the  bodily  temi)erature.  With  this  rise  of  temperature,  or 
following  shortly  thereafter,  there  is  a  chill  that  at  times  merely  amoimts  to  a 
sensation  of  coldness,  at  times  to  a  severe  rigor.  The  temperature  may  shortly 
sink  to  near  the  normal,  but  soon  again  rises  to  a  point  higher  than  that  pre- 
viously attained.  The  fall  of  temperature  may  not  occur  until  the  following 
morning,  the  second  elevated  point  being  usually  observed  upon  the  evening 
of  the  dav  after  the  onset.  From  this  time  the  temperature  assumes  a  peculiar 
type,  with  high  elevations  toward  evening,  and  a  fall  of  oftentimes  three,  four, 
or  more  degrees  toward  the  early  morning  hours.  The  rigors  are  repeated  at 
varvino-  intervals,  but  they  may  not  be  a  marked  feature  of  the  case.  A\  ith 
this  peculiar  temjierature  range  and  the  occurrence  of  rigors  there  is  found  to 
be  a  marked  tendency  to  profuse  sweating.  The  sweating  may  be  almost  con- 
tinuous, or  it  may  occur  in  paroxysms  that  are  apparently  causeless,  but  that 
are  more  apt  to  occur  toward  night-time.  The  patient  rai)idly  loses  strength, 
and  emaciation  progresses  with  constantly  increasing  celerity.  With  the  symp- 
toms enumerated  there  are  loss  of  appetite,  thirst,  a  peculiar  sweetish,  nauseat- 
ing odor,  and  usually  the  signs  of  involvement  of  one  or  more  of  the  internal 
viscera.  The  patient  sinks  into  a  condition  of  profoimd  jjrostration  ;  bed-sores 
form  on  parts  exposed  to  pressure ;  and  the  patient  dies  from  exhaustion  or 
from  involvement  of  some  vital  part  in  the  supi)urative  process. 

When  the  liver  is  the  seat  of  secondary  foci  <»f  su|)|)urati(»n,  a  more  or  less 
intense  yellow  discoloration  of  the  conjunctivie  and  skin  will  !.<•  dcveloi)ed, 
with  in  manv  cases  a  varying  amount  of  diarrh(ea,  and  <.n  percussion  there  is 
shown  to  be'eidargcment  of  the  organ  with  tenderness  over  its  site.  Involve- 
ment of  the  kidneys  may  give  no  sign  ;  more  rre(|.i.iitlv,  h..wever,  there  is  :,I1)U- 
minuria  with  granular  casts,  and  at  times  bl.-o'l.  Splenie  inrmviin,,  is  shown 
by  pain  in  the  left  hypochondriac  region,  will,  j.rogressive  enlargeinent  ul  il„. 
area  of  dulness.    Metastasis  to  thr  Inngs  usually  is  p.H..luctive  of  but  f.-w  changes 


328  SEPTICEMIA    AND   PYEMIA. 

in  the  physical  signs,  save  those  of  the  accompanying  inflammatory  conditions. 
Intestinal  involvement  is  accompanied  by  marked  diarrhoea,  cansing  errors  to 
be  freqnently  made  by  its  simnlating  the  diarrhoea  of  typhoid  fever.  Metas- 
tatic infarctions  of  the  derm  prodnce  multiple  superficial  abscesses.  Secondary 
abscesses  may  also  occur  in  the  parotid  gland  and  in  the  pancreas,  giving  rise 
in  the  latter  to  deep-seated  pain  in  the  epigastric  and  umbilical  regions. 
Abscess  of  the  brain  may  give  rise  to  various  forms  of  paralysis,  but  the 
lesions  are,  as  a  rule,  multiple,  and  hence  give  rise  to  no  trustworthy  local- 
izing symptoms.  One  other  form  must  be  mentioned,  wherein  the  joints  are 
attacked,  giving  rise  to  what  is  known  as  pyajmic  rheumatism. 

The  pathology  of  the  condition  has  been  already  indicated.  Upon  post- 
mortem examination  it  may  be  difficult  to  determine  the  primary  source  of 
infection.  The  abscesses  that  form  in  the  various  organs  are  multiple,  and 
usually  do  not  attain  to  large  dimensions  before  death  occurs.  In  some 
cases,  however,  owing  to  the  fusion  of  smaller  abscesses  or  owing  to  the 
embolus  obstructing  a  large  arterial  branch,  one  large  abscess  may  be  present. 
In  the  secondary  deposits  there  can  be  found  the  pyogenic  micro-organisms 
that  are  accountable  for  their  production. 

The  diagnosis  is  usually  readily  made  by  observing  the  peculiar  irregu- 
larly intermittent  fever.  Tlie  two  diseases  with  which  this  condition  is  most 
apt  to  be  confounded  are  typhoid  fever  and  malaria.  A  careful  review  of 
the  iiistory  of  the  case,  due  attention  to  the  course  of  the  temperature,  the 
appearance  of  the  countenance,  the  absence  of  marked  sweating  and  of  rigors, 
with  the  presence  of  the  typical  eruption,  the  characteristic  stools,  the  tym- 
pany, and  splenic  enlargement,  will  usually  indicate  typhoid  fever.  Malaria 
can  be  readily  distinguished  by  the  greater  regularity  of  the  fever,  the  periodic 
occurrence  of  the  rigors  and  sweating,  the  completeness  of  the  intermission,  the 
specific  action  of  quinine,  and  finally  the  presence  of  the  plasraodium  malariae 
in  a  patient  suffering  from  the  malarial  infection.  The  diagnosis  is  not  suf- 
ficiently accurate  until  not  only  the  condition  of  pysemia  is  determined,  but 
the  lesion  that  gave  birth  to  it  is  discovered. 

The  prognosis  is  in  all  but  the  mildest  cases  extremely  grave.  Where 
the  disease  is  well  marked,  and  where  surgery  cannot  be  called  to  our  aid  to 
evacuate  the  secondary  depots  of  pus,  recovery  is  rare.  Unfavorable  signs  are 
those  indicating  involvement  of  the  deeply-seated  organs. 

Unfortunately,  but  little  can  be  done  in  the  way  of  treatment,  save  where 
the  secondary  abscesses  are  amenable  to  surgical  interference.  All  our  measures 
must  be  directed  to  keeping  up  the  patient's  strength.  A  nutritious  diet, 
moderate  doses  of  quinine,  with  suitable  amounts  of  alcohol,  are  our  chief 
mainstay.  Digitalis,  caifeine,  or  strychnine  may  at  times  be  of  use.  For 
the  sweating,  atropine,  aromatic  sulphuric  acid,  or  agaririn  internally,  with 
sponging  of  the  body  with  alcohol  and  alum,  may  be  resorted  to.  Pain  is 
rarely  severe,  but  may  require  the  use  of  morphine.  The  chief  indication  is 
to  support  the  patient  until  surgical  interference  for  the  evacuation  of  second- 
ary foci  may  become  possible. 


ACUTE  MILIARY  TUBERCULOSIS. 

By  \V.  oilman   THOMPSON. 


Definition. — Acute  miliary  tuberculosis  is  a  form  of  tubercular  infection 
characterized  by  the  general  dissemination  of  minute  tubercles  throughout  the 
various  organs  of  the  body,  by  pyrexia,  constitutional  .symptoms,  and  a  rapidly- 
fatal  ending. 

Etiology. — Acute  miliary  tuberculosis  may  occur  at  any  period  from 
infancy  to  sixty  years  of  age,  but  it  is  most  common  between  the  age  of 
puberty  and  middle  life. 

Acute  miliary  tuberculosis  may  follow  upon  a  tubercular  pleurisy  or  vari- 
ous bone  and  joint  diseases  of  tubercular  origin  witii  caries  and  necroses,  or 
tubercular  lymph-glands  with  cheesy  degeneration.  It  not  infrequently  occurs 
in  connection  with  a  tubercular  psoas  abscess  or  with  the  scrofulous  diathesis ; 
hence  it  is  very  often  a  secondary  disease.  Reich  reports  a  remarkable  occur- 
rence in  Neuenburg,  a  town  of  1300  people.  The  midwifery  practice  of  the 
town  was  divided  between  two  women.  One  of  these  midwives  acquired 
pulmonarv  tuberculosis.  She  was  in  the  habit  of  resuscitating  stillborn 
infants  by  applying  her  mouth  to  theirs  and  breathing  into  their  lungs.  In 
the  course  of  two  years  ten  of  these  infants  died  of  miliary  tuberculosis,  which 
aflected  chiefly  the  meninges,  while  in  the  practice  of  the  healthy  midwife  no 
such  fatality  resulted,  and  the  parents  of  these  children  were  not  tubercular. 

Similar  infection  has  occurred  among  Jewish  children  after  the  rite  of  cir- 
cumcision when  the  operator,  having  pulmonary  tuberculosis,  has  applied  his 
lips  to  the  incision.  Occasionally  operation  upon  tul)ercular  joints  or  upon 
tubercular  bones  with  incomplete  removal  has  been  followed  by  miliary 
tuberculosis. 

None  of  these  various  conditions,  however,  are  necessary  forerunners  of 
miliary  tuberculosis,  and  the  disease  occurs  sometimes  in  persons  who  are  in 
good  health — at  least  in  whom  no  caseous  or  tulx-rcular  foci  or  tubercle  bacilli 
have  been  discoverable.  The  cause  of  this  sudden  inftn-tion  by  miliary  tuber- 
culosis of  the  entire  body  in  persons  previously  in  ap|)arent  health  is  undecided. 
It  is  not  directly  due  to  the  entrance  of  any  virus  through  the  lungs,  and  it 
does  not  follow  acute  pulmonary  inflammations.  It  was  long  ago  suggested 
bv  Buhl  that  it  was  owing  to  the  sudden  liberation  of  caseous  material  from  a 
circumscril)ed  focus  by  ulceration  into  a  blood-vessel  or  lymphatic  vessel.  In 
snp])ort  of  this  theory  is  the  fact  that  l»oiili<'k  discovered  caseous  iuliitration 
of  the  walls  of  the  thoracic  duct  in  children  who  had  died  of  miliary  tuber- 

:j2u 


330 


ACUTE    MfLTARY    rUBERCULOSLS. 


culosis.  A  few  years  later  Weigert  found  similar  appearances  in  the  walls  of 
the  pulmonary  veins.  Under  similar  circumstanees  it  would  be  easy  for  a 
lymphatic  gland  to  adhere  to  the  wall  of  a  vein,  ulcerate  into  it,  and  pour  its 
products  into  the  circulating  blood. 

On  the  contrary,  miliary  tuberculosis  is  a  very  unusual  complication  of 
advanced  pulmonary  phthisis,  and,  indeed,  of  many  other  conditions  in  which 
there  are  large  caseous  deposits  of  long  standing. 

Since  the  discovery  of  the  bacillus  of  tuberculosis  by  Koch  in  1881  the 
theory  has  been  advanced  that  miliary  tuberculosis  is  not  occasioned  by 
caseous  or  other  infections  material  present  in  the  circulation,  but  by  the 
bacilli  themselves,  which,  having  escaped  into  the  blood,  find  lodgment  in  the 
different  viscera  and  serve  as  foci  for  the  development  of  countless  tubercles. 
In  support  of  this  recent  theory  is  the  fact  that  the  injection  of  Koch's  tuber- 
culin into  tuberculous  subjects  occasionally  excites  acute  miliary  tuberculosis. 

Koch's  tuberculin  is  a  glycerin  extract  prepared  from  a  culture  medium  in 
which  tubercle  bacilli  have  been  growing.  It  is  diluted  with  distilled  water 
at  the  moment  of  use,  and  one  milligram,  gradually  increased  to  five  or  more, 
constitutes  the  dose,  given  by  hypodermic  injection.  According  to  Koch,  the 
glycerin  extract  contains  pejitone,  albumose,  and  other  undefined  proteids  and 
salts :  it  is  a  viscid,  thin,  syrupy  fluid  with  a  neutral  reaction,  faintly  aromatic 
odor,  and  the  color  resembles  diluted  iodine.  When  diluted  with  water  it  is 
opalescent  and  greenish. 

The  action  of  tuberculin  upon  tubercular  subjects  is  both  local  and  constitu- 
tional. In  from  four  to  five  hours  after  the  first  inoculation  it  produces  febrile 
symptoms.  There  is  a  chill  with  nausea  and  vomiting,  headache,  malaise, 
aching  of  the  limbs,  and  a  sharp  rise  of  temperature  to  103°  or  105°  F.  A 
few  hours  later  the  local  symptoms  appear.  If  there  be  a  tubei'cular  joint  or 
skin  or  gland  lesion,  there  is  local  swelling,  redness,  and  pain,  accompanied  by 
exudation  and  infiltration  of  the  tuberculous  tissue  with  leucocytes.  Similar 
changes  occur  at  the  site  of  tubercular  processes  in  the  lungs  and  elsewhere. 
The  tuberculin  does  not  kill  the  tubercle  bacilli,  but  modifies  the  nutrition  of 
the  tissues  that  surround  them,  and  it  has  no  influence  on  necrosed  bone  or 
old  cheesy  material.  Living  bacilli  and  caseous  detritus  have  been  found  in 
the  sputum  after  tuberculin  inoculation.  In  other  instances  the  bacilli  become 
encapsulated,  and  are  thereby  rendered  innocuous.  In  still  other  cases,  how- 
ever, patients  have  been  found  to  suddenly  develop  acute  miliary  tuberculosis. 
This  is  due  to  the  local  inflammatory  process  excited  by  the  tuberculin,  result- 
ing in  a  communication  between  a  tubercular  lymph-gland,  or  other  focus  of 
tubercular  material,  and  a  vein  or  lymphatic  trunk.  In  this  manner  the 
bacilli  pass  into  the  circulation,  and  are  borne  to  all  parts  of  the  body  to 
excite  the  formation  of  fresh  tubercles.  This  occurrence  is  not  very  frequent, 
but  well-marked  cases  have  been  described  by  Virchow  and  others.  The  use 
of  tuberculin,  although  so  disajipoiuting  in  its  benefits,  has  proved  of  excep- 
tional interest  by  adding  to  the  knowledge  of  this  mode  of  exciting  acute 
miliary  tuberculosis. 


MORIiTD    AX  ATOM  v.  3-^1 

Morbid  Anatomy. — After  doadi  the  hodv  j)ros(Mits  tin-  iippcaiaiu-e  cuiiinu)ii 
to  acute  febrile  disease.  Tlie  l)loud  is  dark  and  fluid,  the  sj)leen  is  softer  than 
normal,  and  there  may  be  more  or  less  visceral  congestion.  The  muscles  are 
refl  and  rigor  mortis  is  well  marked. 

For  the  detailed  structure  of  tubercles  the  reader  is  referred  to  the  article 
upon  Pulmonary  Plitlnsia.  They  present  no  anatomical  peculiarities  in 
miliary  tuberculosis,  excepting  in  regard  to  their  extension  and  uuitbrm 
distribution  through  many  organs  and  tissues  of  the  body.  The  tubercles 
vary  in  size  from  3^^^  to  2-jo  ^^^  '^"  '"^'^*  '"  <biiiiieter.  Submiliary  tuber- 
cles are  also  found,  and  the  masses  may  l)e  as  large  as  a  split  pea.  Such 
masses  are  composed  of  aggregations  of  the  miliary  nodules.  When  newly 
formed  thev  are  gray,  translucent,  and  somewhat  firm  in  consistence,  so 
that  thev  can  be  picked  out  with  the  point  of  a  scalj)el.  They  commonly 
possess  the  epithelioid  and  giant-cell  structure  which  is  typical  of  such 
growths,  or  they  are  merely  minute  foci  of  tubercular  iuHainmation.  The 
outer  wall  of  the  arterioles  is  often  thickened  by  intiltratinn  with  lymphoid 
cells.     Such  structure  is  often  found  in  the  vessels  of  the  pia  mater. 

Sometimes  inflammatory  products  or  granulation  tissue  are  mixed  with  the 
tubercular  growths.  The  miliaiy  tubercles,  when  newly  formed,  are  often 
found  to  contain  tubercle  bacilli.  Older  tubercles,  especially  caseous  ones,  con- 
tain few  or  no  bacilli. 

The  disease  usually  runs  such  a  brief  course  that  few  if  any  of  the  tubercles 
have  an  op])ortunity  to  undergo  caseous  change,  as  they  do  in  indmonary 
phthisis.  In  more  protracted  cases  they  may  become  caseous  and  yellow  ; 
sometimes  the  centre  only  of  the  tubercle  is  caseous  and   friable. 

The  luno-s  are  filled  throughout  with  minute  tubercles,  which  can  for  the 
most  part  be  seen  with  the  naked  eye  and  distinctly  felt  between  the  fingers. 
They  may  also  involve  the  pleura.  The  tubercles  are  grayish  and  translucent, 
and  the  larger  yellow  cheesy  masses  and  abscess-cavities,  which  are  irregularly 
disposed  in  chronic  pulmonary  tuberculosis,  are  wanting,  unless  the  latter  dis- 
ea.se  has  previously  invaded  the  lungs,  which  is  not  usually  the  ca.sc.  Tubercles 
are  found  in  the  parenchyma  of  the  lungs,  and  they  invade  the  walls  of  the 
air-cells.  The  air-cells  between  the  tubercles  contain  more  or  less  detritus  of 
granular  matter,  desquamated  epitliclium,  or  inflammatory  |)rodncts,  fibrin, 
and  pus  in  small  quantities.  The  tubercles  also  occur  in  the  walls  of  the 
bronchi  and  pulmonary  blood-vessels.  They  are  frequently  discrete,  but  inav 
be  very  close  together  or  occasionally  gathered  in  masses  as  large  as  a  |)ca. 
The  lesions  of  extensive  acute  catarrhal  bronchitis  may  accomi)any  the  tuber- 
cular extension  in  the  lungs.  In  children's  lungs  the  miliary  tubercles  often 
attain  a  lai-gc  size. 

In  the  liver  and  spleen  tubercles  also  wcur  in  Inrgc  nund)crs,  but  they  arc 
of  microscopic  size.  The  spleen  is  not  imicli  cnlargc<l.  bnl  may  be  slightly  so. 
In  the  liver  the  tubercles  are  foun<l  both  within  the  lobules  and  in  the  inter- 
lobidar  connective  tissue,  the  latter  being  often  increase<l  in  aniuiinl. 

The  endocardium   may  contain   tiibeivles.     The  iyiu|.h--l:in(ls,  peritonemn, 


332  ACUTE   MILIARY    TUBERCULOSIS. 

and  omentum  may  be  filled  with  them,  and  peritonitis  may  be  excited.  Tuber- 
cular granules  are  also  found  in  the  marrow  of  the  bones,  such  as  the  vertebrae, 
sternum  and  ribs,  and  in  the  kidney.  In  the  latter  there  may  be  only  infil- 
tration of  lymphoid  cells. 

The  tubercles  invade  the  pia  mater,  especially  at  the  base  of  the  brain. 
They  are  found  upon  the  membrane  over  the  pons,  oj)tic  chiasma,  etc.  This 
condition  is  often  present  in  cases  which  attack  the  young. 

The  invasion  of  the  choroid  by  tubercles  was  first  observed  by  Manz  and 
Cohnheim.  They  can  be  distinguished  in  the  eye  during  life  by  an  expert 
ophthalmologist,  although  they  are  somewhat  difficult  to  demonstrate.  They 
commonly  develop  near  the  yellow  spot  or  the  disk,  or  they  may  occur  through- 
out the  choroid.  When  present  in  a  doubtful  case  they  make  the  diagnosis  ab- 
solutely certain.  They  vary  in  diameter  from  1  to  2.5  mm.  The  tubercles 
may  occur  anywhere  in  the  body,  but  they  are  rare  in  the  skin,  mucous  mem- 
brane, or  muscles,  and  seldom  occur  in  the  j)ancreas  or  salivary  glands. 

Symptomatolog'y. — The  symptoms de])cnd  upon  the  general  infection  and 
the  extent  of  the  local  lesions. 

In  a  typical  case  of  acute  miliary  tuberculosis  the  symptoms  are  as  follows  : 
The  patient  complains  of  malaise,  anorexia,  prostration,  and  fever  for  two  or 
three  days.  The  pulse  is  accelerated,  and  there  is  a  sensation  of  thoracic 
oj)pression.  The  temperature  rises  rapidly  in  a  few  days  to  about  104°  F., 
tiiough  it  presents  no  regular  course.  Respiration  becomes  greatly  accelerated, 
and  finally  its  rate  reaches  40  or  50,  or  even  60,  per  minute.  The  pulse 
may  be  140.  There  is  marked  pallor  and  cyanosis,  and  lips,  cheeks,  and 
tinger-tips  become  purple.  Without  special  pain,  the  patient  feels  very  ill 
and  dull,  and  prostration  becomes  more  and  more  marked.  There  is  a  cough 
which  may  be  dry  and  obstinate,  or  there  may  be  muco-purulent  sputum. 
The  rapid  pulse  and  respiration  continue,  the  temperature  is  irregular,  but 
often  of  a  remittent  type,  and  the  patient  passes  into  a  typhoid  condition.  If 
tiie  serous  membranes  are  affected,  the  temperature  remains  higher.  Nervous 
sym])toms  develop:  there  may  be  muscular  twitchings  and  carphologia.  The 
dulness  deepens  into  coma,  or  there  is  a  low  muttering  delirium  ;  the  tongue 
is  brown,  dry,  and  fissured;  there  is  herpes  labialis;  the  evacuations  become 
involuntary  ;  and  the  patient  dies  in  collapse  or  coma,  with  pulmonary  oedema. 
Tliere  may  be  uncontrollable  perspiration,  producing  sudamina,  and  occa- 
sionally there  is  a  roseola  upon  the  chest  and  abdomen.  Albuminuria  is  fre- 
quently observed,  and  sometimes  peptonuria  is  present.  The  mind  may  remain 
clear  until  the  approach  of  death,  but  the  patient  frequently  becomes  dull  and 
listless,  or  there  may  be  anxiety,  restlessness,  and  delirium.  Acute  mania 
has  been  observed. 

Special  Symptoms. — The  onset  is  usually  gradual,  as  in  the  case  de- 
scribed, but  it  may  be  acute,  with  one  or  more  rigors  and  rapid  rise  of 
temperature. 

The  pulse  is  always  rapid,  and  it  soon  becomes  very  feeble  and  com- 
pressible.    It  ranges  between  120  and  160. 


/'//  }  'S/(  'A  L    SiaXS.—CO  I  'RSE. 


333 


The  tompcrature  is  very  irregular.  (See  Fig.  22.)  It  may  he  intermit- 
tent or  remittent,  or  the  evening  fever  may  he  higher  than  the  morning. 
Just  hefore  death  it  may  rise  to  107°  or  108°  F.  In  some  ca.ses  it  remains 
as  low  a.s  102°  throughout  the  disease.  Not  rarely  the  morning  temperature 
is  higher  than  that  of  the  evening.  Some  Avriters  divide  the  disea.se  into 
two  types,  based  upon  the  eharacter  of  the  fever — namely,  the  "tyi)hoid  "  and 
the  ''intermittent"  forms. 

Ficj.  22. 


Tenipcralurc  Churl  of  Case  ol  Acute  Miliary  Tuberculosis  tWunilerlith). 


The  tenijierature  depends  upon  the  infection  of  the  blood  rather  than  upon 
the  extent  of  tubercular  deposit. 

The  resj)iration  is  always  accelerated.  It  may  be  deep  at  first,  but  .soon 
becomes  shallow.  The  accessory  respiratory  muscles  are  called  into  action  and 
the  no.stri]s  work.  The  i)atient  does  not  always  complain  of  shortness  of 
breath.  In  young  children  the  respiration  may  exceed  85,  and  in  adults  it 
occasionally  rises  above  60. 

There  is  usually  more  or  less  bronchitis,  which  excites  a  hacking,  dry  cough 
or  gives  ri.seto  expectoration,  which  may  be  clear  and  frothy  or  muco-purulent. 
Rarely  the  sputum  is  streaked  with  blood.  Tubercle  bacilli  are  not  found  in 
the  sputum  unless  there  was  a  pre-existent  phthisis.  ILcmoptysis  is  not  a  Ha- 
ture  of  the  disease.  There  may  be  a  few  rigors  at  fir.st,  and  there  is  more  \)v\- 
spi ration  as  the  prostration  advances. 

Vomiting  may  occur  at  the  onset,  but  there  is  nothing  typical  about  it. 

The  bowels  are  often  cou-;tipated. 

The  lu-ine  shows  the  modification.s.  produced  by  any  febrile  state,  and  then- 
may  be  slight  albuminuria. 

Physical  Signs. — The  disease  is  characterized  by  the  jx'culiar  absence  of 
phy.sical  signs  in  the  chest.  Previously  exi.sting  phthisis  is  occasionally  |)res- 
ent,  and  there  is  commonly  cnongh  bronchitis  to  occasion  a  few  nioi.st  rAles  or 
rhonchi,  and,  if  there  be  a  (ul)cr<iil:ir  plciu'isy,  there  may  be  friction  sounds; 
but  ncitiier  percus.sion  nor  carcfii!  auscultation  reveals  any  signs  <lir(ctly  altrib- 


334  ACUTE   MILIARY    TUBERCULOSIS. 

utable  to  the  miliary  tubercles,  even  though  they  may  be  present  in  the  lungs 
in  great  numbers.  The  reason  for  this  is  that  the  tubercles  do  not  involve  or 
compress  the  air-cells  to  any  extent,  nor  are  they  close  enough  together  to  mod- 
ify in  any  manner  the  percussion  or  auscultatory  sounds  of  the  chest. 

Course. — The  course  of  the  disease  will  vary  Avith  the  predominance  of 
certain  svmptoms,  in  accordance  with  the  degree  of  involvement  of  various 
organs.  In  some  cases  the  typhoid  condition  is  the  prominent  feature  ;  in 
others,  the  subjective  dyspnoea,  cyanosis,  and  rapid  breathing,  or  uncontrol- 
lable constant  dry  cough  ;  in  others,  symptoms  of  peritoneal  tuberculosis  are 
distinctive;  and  finally  tubercular  invasion  of  the  meninges  of  the  brain  may 
occasion  symptoms  so  severe  that  they  divert  attention  from  the  possibility  of 
a  general  infection.  In  the  latter  variety  the  tubercles  involve  the  base  of  the 
brain  chiefly,  and  occur  near  the  pons,  optic  chiasma,  or  in  connection  with  the 
cranial  nerves.  There  are  violent  headache,  delirium  or  stupor,  photophobia; 
and  frequently  symptoms  of  local  pressure  are  evident,  as  unilateral  convul- 
sions or  paralyses  of  the  extremities  or  facial  muscles,  strabismus,  and  varia- 
tions in  size  of  the  pupils.  There  is  rigidity  of  the  back  of  the  neck.  There 
is  usually  extreme  dyspnoea  in  this  variety  of  the  disease. 

Exceptionally,  the  disease  exhibits  a  somewhat  intermittent  type,  and  the 
course  is  jirotracted  for  several  weeks  by  irregular  remissions,  or  even  inter- 
missions and  exacerbations,  of  the  fever  and  other  symptoms. 

The  duration  of  the  disease  is  commonly  between  three  and  four  weeks. 
Exceptionally,  bad  cases  are  fatal  in  ten  days,  while  mild  cases  sometimes 
are  prolonged  for  as  many  weeks. 

The  patient  commonly  dies  of  exhaustion  from  the  fever  and  the  systemic 
effects  of  the  virus,  or  death  results  from  pulmonary  oedema  or  from  simple 
heart  failure.     The  disease  is  uniformly  fatal. 

Diag-nosis. — The  diagnosis  is  largely  based  upon  the  exclusion  of  grave 
forms  of  pulmonary  disease  and  the  presence  of  the  extreme  dyspnoea  and 
prostration  with  fever,  and  a  ra})id,  feeble  pulse. 

Acute  miliary  tuberculosis  is  distinguished  from  meningitis  by  the  greater 
frequency  of  pulse  and  respiration,  the  clearer  mental  condition,  and  the  lack 
of  the  distinctly  cerebral  symptoms  which  belong  to  the  latter  disease. 

There  are  some  cases  of  acute  miliary  tuberculosis  which  so  closely  resem- 
ble typhoid  fever  that  it  is  almost  impossible  to  make  a  diagnosis  with  abso- 
lute certainty.  These  are  the  cases  of  the  "typhoid"  type  in  which  the  pyrexia, 
j)rostration,  and  general  appearance  are  almost  identical  with  the  symptoms  of 
enteric  fever.  The  diagnosis  must  be  based  upon  the  following  features :  In 
typhoid  fever  there  is  frequently  an  eruption  of  rose-colored  spots  on  the  abdo- 
men, back,  and  possibly  the  extremities.  There  is  enlargement  of  the  spleen 
and  more  or  less  tympanites,  with  some  "  pea-soup  "  stools.  There  is  the  his- 
tory of  a  slow  invasion,  with  marked  frontal  headache,  epistaxis,  and  gradual 
daily  rise  of  temperature  during  the  first  week.  In  miliary  tuberculosis,  on 
the  other  hand,  the  invasion  and  prostration  are  more  sudden,  the  temperature 
is  more  irregular,  there  is  marked  ra])idity  of  respiration  with  a  very  rapid 


TREA  r.VKXT.  335 

j>ulsp,  and  there  is  no  abdominal  eruption  or  splenic  enlargement.  The  dis- 
ease advances  much   more  raj>idly  than  does  typhoid  fever. 

When  there  are  chills  at  the  onset  the  disease  has  been  sometimes  mistaken 
for  malarial  fever;  but  the  typical  paroxysms,  the  enlarged  spleen  of  the  latter 
disease,  and  the  influence  of  quinine  will  establish  the  diagnosis. 

If  there  be  much  cough  and  expectoration,  miliary  tuberculosis  may  be  mis- 
taken for  a  .severe  acute  general  bronchitis,  especially  in  advanced  life  ;  but  the 
mor(>  rapid  prostration,  extremely  rapid  breathing,  and  rapid  pulse  of  miliary 
tuberculosis  soon  resolve  the  doubt. 

Prognosis. — The  prognosis  is  always  bad.  It  is  generally  believed  that 
recovcrv  is  impossible,  and  that  reported  recoveries  were  instances  of  errors 
in  diagnosis.  Death  will  occur  sooner  in  proportion  to  the  number  of 
different  organs  involveil  and  the  suddenness  and  severity  of  the  invasion. 
Death   occurs  early   in  cases  with  meningeal  tubercles. 

Treatment. — The  treatment  is  purely  symptomatic,  and  remedies  given 
with  anv  other  view  are  useless.  Th.e  only  indications  which  can  be  met 
are  to  stimulate  the  heart  and  to  relieve  the  dyspnoea  or  other  suflering  l)y 
morphine. 

If  the  temperature  be  very  high,  cold  alcohol  sponge-baths  may  be  given  ; 
cardiac  stimulants  and  alcohol  must  be  administered  to  sustain  the  heart.  The 
diet  must  consist  of  milk,  broths,  eggs,  beef-juice,  egg-nog,  milk-punch,  etc. 

If  there  be  meningeal  complication,  to  relieve  headache  and  delirium  leeches 
mav  be  applied  behind  the  temples  and  an  ice-bag  ])laced  upon  the  luuid. 
Severe  cough  should  be  controlled  by  sedatives  and  narcotics.  Small  hypo- 
<lermic  injections  of  morphine  may  be  given  to  quiet  restlessness  and  make 
the  patient  more  comfortable.  Codeine  in  half-grain  doses  acts  well  in  reliev- 
ing cough  and  restlessness. 


SCROFULA. 

By  W.  oilman   THOMPSON. 


Definition. — Scrofula  is  not  a  distinct  disease,  for  it  has  no  symptoms  or 
lesions  peculiarly  its  own  ;  but  it  is  a  morbid  condition  of  the  system  or  a 
diathesis  resulting  from  malnutrition  and  characterized  by  hyperplasia  and 
inflammation,  with  caseation  or  suppuration  of  the  lymphatic  glands,  and  by 
a  tendency  to  tedious,  intractable  inflammations  of  tiie  skin,  mucous  mem- 
branes, bones,  and  joints.  Persons  are  called  scrofulous  who  exhibit  this 
morbid  tendency,  although  at  the  time  they  may  not  be  actually  suffering  from 
any  lesion.  Many  cases  which  formerly  were  described  as  scrofulous  are  now 
recognized  as  tuberculous  or  due  to  hereditary  syphilis. 

Synonyms. — Scrofulosis  ;  Morbus  scrophulosus  ;  Scrophulose,  Skrofeln 
(Ger.) ;  Scrofule,  Scrofulose  (Fr.) ;  King's  Evil;  the  Eyil ;  Quince; 
Gruels.  Struma  is  used  synonymously  with  scrofula  by  certain  English 
writers.  In  Germany  the  name  struma  is  applied  to  enlargement  of  the  thy- 
roid gland.  When  the  cervical  glands  are  greatly  swollen  the  normal  con- 
striction between  the  head  and  shoulders  is  obliterated,  and,  as  in  the  pig,  there 
is  no  neck  ;  hence  the  name  scrofula,  from  serofa,  a  pig. 

Etiolog-y. — Scrofula  as  a  morbid  tendency  is  either  hereditary  or  acquired, 
and  it  is  so  closely  related  to  tuberculosis  that  many  believe  the  scrofulous  con- 
dition to  be  merely  one  of  the  manifestations  of  chronic  tubercular  disease. 
There  is  some  dispute  as  to  the  hereditary  nature  of  scrofula.  The  term 
"  hereditary  "  must  not  be  regarded  as  implying  that  the  scrofulous  lesions  are 
congenital,  but  merely  that  the  constitution  of  the  infant  is  so  modified  by  its 
inheritance  that,  although  it  may  be  born  in  a  fairly  healthy  condition,  its 
feeble  resisting  power  very  soon  succumbs  to  the  scrofulous  taint  and  the 
development  of  the  various  scrofulous  lesions.  Viewed  in  this  light,  the 
majority  of  cases  are  "  hereditary."  Hereditary  scrofula  manifests  itself  in  the 
offspring  when  one  or  both  parents  are  themselves  scrofulous,  the  subjects  of 
phthisis,  carcinoma,  other  wasting  disease,  or  chronic  alcoholism  ;  or  when 
both  parents  are  very  young,  too  old,  when  there  is  too  great  a  difference 
between  their  ages,  or  when  they  are  closely  related  by  blood.  It  is  true  that 
the  marriage  of  such  parents  may  be  followed  by  the  birth  of  healthy  chil- 
dren, but  they  are  far  more  apt  to  be  scrofulous,  especially  when  both  parents 
are  at  fault. 

Acquired  scrofula  may  occur  in  children  who  were  previously  perfectly 
healthy.  Poor  hygienic  surroundings  influence  the  development  of  scrofula  as 
much  as  any  single  factor.     Foul  air,  damp,  dark,  ill-ventilated  rooms,  over- 

336 


ETIOLOGY.  337 

crowding:,  indoor  life,  insufficient  and  impmpcr  diet, — all  promote  the  develop- 
ment or  acquirement  of  the  diatliesis. 

LocaUtij,  climate,  and  season  have  no  influence  beyond  the  general  hygienic 
conditions  which  they  favor.  Thus,  scrofula  is  most  frequently  encountered 
in  the  temperate  zone  in  a  severe  winter  or  a  damp  spring-time,  and  in  a  cold, 
moist  locality  which  begets  frequent  catarrhs  or  compels  an  indoor  life. 

A  diet  of  coarse,  starchy  food,  without  sufficient  nitrogenous  material,  is  a 
potent  factor  in  the  development  of  scrofuhi.  Children  nursed  by  a  healthy 
mother  are  much  less  apt  to  become  scrofulous  than  if  they  are  fed  upon  arti- 
ficial infant  foods. 

Sex  has  no  special  influence  upon  scrofula,  but  females  are  more  apt  to  sufficr 
from  the  glandular  lesions,  and  males  from  caries  (Lvncii). 

Age. — Scrofula  is  essentially  a  condition  of  childhood.  It  is  rare  in  the 
first  year,  and  is  commonest  between  the  ages  of  two  and  fourteen  years,  or 
from  the  establishment  of  the  first  dentition  to  puberty.  It  may  exceptionally 
develop  somewhat  later  in  life  or  be  acquired  after  puberty.  It  may  thus 
occur  among  inmates  of  overcrowded  workhouses  or  prisons,  but  is  very  rare 
after  twenty-five  or  thirty  years  of  age. 

Social  Conditions. — Scrofula  is  far  more  common  among  the  children  of 
the  very  poor,  owing  to  unfavorable  diet  and  lack  of  proper  hygienic  sur- 
roundings, but  it  is  by  no  means  unknown  among  the  children  of  the 
wealthy,  in  whom  heredity,  overwork  in  school,  and  dietetic  errors  are  jirc- 
disposing  causes. 

Bace. — In  the  United  States  the  Irish,  negroes,  and  the  Hebrew  children 
seem  to  be  the  most  frequent  subjects  of  scrofulosis.  It  has  been  suggested 
that  this  may  be  due  to  the  quality  of  the  food  in  previous  generations. 

Scrofula  is  less  frequently  observed  than  formerly,  now  that  its  causation 
and  treatment  are  understood,  and  it  is  less  common  in  the  United  States  than 
in  Europe. 

The  scrofulous  diathesis  may  be  evoked  as  a  sequel  to  measles,  scarlatina, 
frequent  attacks  of  croup,  and  other  debilitating  diseases  of  childhood. 

Many  German  pathologists,  led  by  Koch,  regard  scrofula  as  a  special  clin- 
ical form  of  chronic  tuberculosis  of  the  lymi)h-glands,  owing  its  existence  to 
tubercle  bacilli.  Striimpell  says  that  most  scrofulous  children  do  not  become 
tubercular,  but  they  already  are  so.  Others  believe  tliat  scrofula  is  not  identi- 
cal with  tuberculosis,  because  the  tubercle  bacilli  cannot  invariably  be  discov- 
ered in  scrofulous  subjects,  and  in  many  such  persons  tubercular  tissue  is  not 
l)roduced.  Tuberculosis  is  readily  inoculated  in  non-scrofulous  animals  and 
men,  and  it  is  n(»t  necessarily  accompanied  by  the  enlargement  of  the  lym- 
phatic glands  which  is  so  common  in  scrofula.  It  is  also  true  that  fatal  cases 
of  phthisis  seldom  exhibit  scrofulous  symj)toms  or  lesions.  TIic  scrofulous 
diathesis  is  often  inherited,  but  tuberculosis  is  not  ;  yet  scroCiiloMs  subjects  are 
very  prone  to  acquire  tubenrulosis,  because  they  arc  readily  allected  by  an,' 
morbific  influence,  and  their  tissues  aflbrd  I'xcellent  soil  lot-  tlic  dcvclopiiMnt 
of  tubercle  bacilli.  Much  argument  has  been  expended  upon  bolh  sido  of 
Vol..  r.— 22 


338  SCROFULA, 

the  question,  but  the  tendency  is  fast  becoming  universal  to  give  less  promi- 
nence to  scrofula  as  a  morbid  condition,  and  to  include  it  in  descriptions  of 
chronic  tuberculosis. 

In  scrofula  the  system  is  highly  predisposed  to  local  inflammations,  with 
the  added  danger  that  the  inflamed  area,  if  not  originally  tubercular,  may 
easily  become  infected  with  tubercle  (Eichhorst).  Any  inflammation  occur- 
ring in  a  scrofulous  subject  assumes  a  scrofulous  type — i.  e.  it  exhibits  slow 
development  or  chronicity,  lack  of  response  to  treatment,  abundant  cell-pro- 
duction, and  tendency  to  caseation.  The  cellular  infiltration  inclines  to  remain 
permanent,  instead  of  terminating,  as  is  usual  in  non-scrofulous  inflammation, 
in  resolution,  organization,  or  suppuration. 

Morbid  Anatomy. — There  are  no  anatomical  lesions  peculiar  to  scrofula. 
They  belong  rather  to  the  lesions  of  tuberculosis.  The  old  theory  that  scrof- 
ula is  caused  solely  by  altered  and  impoverished  blood  is  abandoned,  although 
the  blood  and  other  alkaline  fluids  of  the  body  may  be  less  alkaline  than  usual. 
Lesions  which  scrofula  exhibits  are  due  primarily  to  cell-proliferation  and 
inflammation.  It  is  a  diathesis  of  childhood,  and  young  children  have  rela- 
tively large  and  numerous  lymph-spaces  and  active  lymph-cells,  and  their  tis- 
sues are  less  compact  than  in  adult  life  (Formad).  In  the  case  of  scrofula  the 
lymphoid  tissues,  either  from  nutritive  disorder  or  some  inherent  peculiarity 
not  yet  understood,  readily  exhibit  abnormal  cell-growth.  The  capillaries 
supplying  such  tissues  are  inadequate,  and  the  tissues  consequently  suffer  from 
a  deficient  supply  of  nutritive  food  (Lynch).  Hence  it  is  that  all  inflamma- 
tory ])rocesses  occurring  in  the  scrofulous  resolve  very  slowly.  There  is  a 
preponderance  of  cellular  elements  in  the  scrofulous  exudations,  and  the  cells 
have  low  vitality  (Virchow). 

The  common  lesions  of  scrofula  are  those  of — 

(1)  The  lymphatic  glands; 

(2)  The  mucous  membranes  ; 

(3)  The  skin  ; 

(4)  The  bones  and  joints. 

(1)  Enlargement  op  the  Lymphatic  Glands  occurs  so  constantly  at 
one  time  or  another  in  the  course  of  scrofulous  cases  that  it  is  almost  patho- 
gnomonic. The  lymphatic  glands  most  frequently  involved  are  the  cervical 
and  submaxillary.  Other  glands  affected  may  be  the  occipital,  cubital,  axil- 
lary, inguinal,  bronchial,  and  mesenteric.  There  are  two  types  of  scrofulous 
glandular  lesion  : 

(rt)  Simple  hyperplasia  ;  {b)  Inflammation.  They  may  occur  independently, 
or  either  may  })recede  the  other.  Both  are  usually  excited  by  some  irritation 
of  the  adjacent  skin  or  mucous  membrane,  which  results  in  the  production  of 
morbid  materials,  which  are  conveyed  through  the  lymphatic  vessels  to  the 
glands.  Such  irritation  may  proceed  from  disease  of  the  tonsils;  teeth,  ear, 
etc.     The  Koch  tubercle  bacillus  is  found  in  many,  but  not  all  of  the  glands. 

(a)  Simple  hyperplasia,  or  enlargement  of  the  gland  from  nndtiplication  of 
its  cellular  elements,  is  excited  by  exceedingly  slight  irritation,  which  in  the 


MORBID    ANATOMY.  330 

non-scrofiilous  would  produce  no  aj)preciable  effect.  This  liyporplusia  may 
occur  in  a  gland  without  previous  iuHainination,  and  the  process  is  very  grad- 
ual. The  gland  becomes  greatly  swollen,  and  feels  hard,  stnooth,  and  tense. 
It  is  not  painful,  and  is  freely  movable  beneath  the  skin.  Rarely  one  gland 
alone  is  involved  ;  more  often  a  series  of  glands  becomes  enlarged,  forming  a 
knotted  chain.  If  the  cellular  proliferation  continues,  the  glands  will  form  a 
verv  large  mass,  which  disfigures  the  neck  and  interferes  with  the  proper 
movement  of  the  head.  The  microscope  reveals  no  foreign  elements  in  such 
glands,  and  the  tissue  of  the  stroma  is  not  increased.  Since  the  lymphoid  cells 
onlv  are  multiplied,  it  is  easy  to  understand  how  the  enlarged  glands  occasion- 
allv  return  to  the  normal  size,  for  in  health  the  number  of  cells  varies  con- 
siderably. It  is  difficidt  to  trace  the  source  of  the  new  cells.  They  may  come 
to  the  gland  through  the  lymph -channels  from  some  distant  inflamed  area,  or 
they  may  spring  from  the  normal  gland-cells,  or  they  are  j>ossibly  wandering 
leucocytes. 

Sometimes  parts  of  a  gland  undergo  annemic  necrosis  and  form  caseous 
matter  without  active  inflammation,  although  such  a  mass  really  acts  as  a  for- 
eign body,  and  is  liable  to  originate  inflammation. 

(6)  Inflammation,  when  it  affects  the  glands,  causes  an  increase  in  the 
number  of  lymphoid  cells  in  the  sinuses  and  follicles.  The  cells  are 
swollen  and  have  large  nuclei.  The  white  blood-cells  in  the  vicinity  are 
swollen  by  imbibition  of  albumin  (Lynch),  and  they  degenerate.  In  the 
glands  there  are  at  first  hyperemia  and  an  exudation  which  is  either  diffuse 
or  localized,  forming  nodular  masses,  which  may  resolve  or  sup])urate  and  re- 
sult in  abscesses,  or  which  more  often  are  converted  into  a  dry,  friable,  caseous 
material.  In  the  mediastinum  and  mesentery  the  glands  are  apt  to  become 
cretaceous.  The  cut  surface  of  the  gland  shows  irregular  yellowish  or  white 
spots  of  cheesy  or  calcareous  material.  The  spots  may  be  few  and  isolated,  or 
all  the  normal  gland-structiire  be  replaced  by  cheesy  matter  enclosed  by  a  thick- 
ened capsule.  These  ])rocesses  may  be  acute,  but  they  are  usually  very  pro- 
tracted, and  the  glands  quite  lose  their  vascularity  and  often  become  nodular. 
When  the  cellular  elements  undergo  fatty  degeneration  and  caseation,  it  is  be- 
cause the  scanty  blood-supj)ly,  still  further  reduced  by  tiie  i)ressure  of  the 
swollen  gland,  does  not  furnish  enough  alkaline  blood-plasma  to  liquefy  the 
mass,  and  what  is  supplied  is  carried  off  too  rapidly  in  the  relatively  large 
lymph-channels  (Cornil  and  Ranvier).  There  is  periglandidar  innaiiuuati..u 
in  the  surrounding  areolar  tissue,  and  the  caj)sule  of  the  gland  becomes  thick- 
ened and  is  permeated  with  round  cells.    The  overlying  skin  becomes  adherent, 

bluish,  and  thin. 

Giant  cells  and  tubercles  are  very  often  found  in  the  glands,  and  sometimes 
there  are  tubercle  bacilli.  The  enlarged  bronchial  glands  n>ay  produce  pressure 
symptoms,  or  may  supi)urate  and  ulcerate  through  the  bronchial  mucous  mem- 
brane and  occasion  bn^ncho-pncmnonia.  The  cnhugcl  mesenteric  glands  occa- 
sion chronic;  enteritis  and  dlarrlio'a. 

(2)  The  Lesions  oe  the  Mucous  Memhuamos  may  arise  by  extension 


340  SCROFULA. 

from  the  skin,  or  they  may  spread  from  the  mucous  membranes  to  the  skin. 
Hypersecretion  prevails,  and  it  is  excited  by  the  slightest  irritation.  There 
may  be  conjunctivitis,  catarrhal  ophthalmia,  or  suppurative  inflammation  of 
the  middle  ear,  resulting  in  perforation  of  the  membrana  tympani  and  a  muco- 
purulent, offensive  discharge.  Opacities  of  the  cornea  may  be  produced  which 
last  throuo-h  life.  There  is  a  marked  tendency  to  catarrhs  of  the  nose  and 
pharynx,  which  are  very  chronic,  and  the  mucous  membrane  is  covered  with 
thick  exudation  which  encrusts  it,  forming  scabs.  Coryza,  laryngitis,  and 
bronchitis  occur,  and  are  very  persistent.  Inflammations  of  other  mucous 
membranes  are  less  frequent.  Scrofulous  ulcers  are  indolent,  with  anaemic 
overhanging  edges ;  they  heal  very  slowly,  and  often  a  cicatrix  closes  in  one 
part  of  an  ulcer  while  it  breaks  down  again  and  opens  at  another. 

(3)  The  Lesions  of  the  Skin  are  of  considerable  variety.  When  the 
diathesis  exists,  apy  skin  disorder  is  affected  by  it  and  assumes  the  scrofulous 
type.  Impetiginous  eczema  is  the  commonest  of  the  scrofulodermata,  and  the 
face,  hairy  scalp,  or  extremities  are  affected  by  it.  Lupus,  prurigo,  and  lichen 
also  occur. 

(4)  The  Bones  which  are  most  frequently  the  seat  of  scrofulous  changes 
are  those  about  the  ankle,  the  femur,  and  the  vertebrae.  The  character  of  the 
inflammation  is  a  "  fungous "  osteitis  or  periostitis,  and  the  joints  may  be 
affected  by  synovitis,  white  swelling,  or  general  arthritis.  There  may  be  caries, 
necrosis,  and  extensive  suppuration,  ending  in  total  destruction  of  a  joint. 
Tubercle  bacilli  may  be  found  in  most  of  the  fungous  bone-lesions.  The 
bones  and  joints  may  be  diseased  without  glandular  enlargement,  and 
conversely. 

Symptomatolog-y. — Different  scrofulous  patients  rarely  present  identical 
pictures  of  disease,  but  most  of  them  may  be  classed  under  two  general  types. 
These  subdivisions  are  not  very  exact,  and  there  are  many  scrofulous  children 
who  present  the  features  of  neither  or  of  both  in -combination ;  still,  from  a 
clinical  standpoint  it  is  convenient  to  select  distinctive  types  for  description, 
and  the  following  is  the  classification  which  has  long  been  in  use.  The  two 
types  are — I.   The  Eretkitie,  and  II.  The  Phlegniatic. 

I.  The  Erethitic  or  Sanguine  Variety. — In  this  form,  which  is  usu- 
ally hereditary,  the  child  looks  delicate  and  often  pretty.  The  skin  is  fair 
and  transparent,  showing  the  blue  veins  distinctly,  and  blushing  easily  occurs. 
The  eyelashes  are  long,  the  features  are  small,  the  weight  is  light,  the  nuiscles 
are  soft,  and  the  bones  are  slender.  The  hair  is  fine  and  the  teeth  appear 
early.  The  nervous  system  is  apt  to  be  irritable,  with  unnatural  activity,  but 
the  mental  development  is  good.  This  type  is  more  frequent  in  females  than 
males,  and  more  apt  to  furnish  severe  and  even  fatal  cases. 

IL  The  Phlegmatic  Type. — The  phlegmatic  or  torpid  variety  is  more 
apt  to  be  acquired  than  inherited.  The  child  is  stout,  clumsy,  and  thick-set. 
The  expression  is  dull  and  heavy.  The  head  is  large.  The  upper  lip  and 
nose  are  full  and  the  eyebrows  thick.  The  chin  is  prominent.  The  skin  is 
coarse  and  spongy.     The  nervous  system  is  far  less  acutely  irritable  than  in 


TERMIXATIONS   AND    COMPLICATIONS.  341 


the  erethitic  variety.  The  abdomen  is  kirge.  The  cervical  glands  are  increased 
in  size,  and  there  is  nsually  a  naso-pharyngeal  catarrh.  C'liiidreu  with  this 
type  of  scrofula  have  eczema  and  chilblains,  and  their  wounds  heal  poorly. 
The  muscles  are  soft,  and  there  is  over-production  of  subcutaneous  fat.  The 
pulse  is  feeble,  and  the  temperature  at  times  is  subnormal.  In  bad  cases  the 
glandular  enlargement  becomes  extreme,  and  a  number  of  glands  in  the  neck, 
thorax,  or  mesenterv  are  involved.  If  a  uhuid  becomes  acutelv  inflamed, 
there  may  be  local  pain  and  moderate  fever,  which  disappear  after  extirpation 
of  the  gland  or  incision  of  the  abscess.  In  addition,  any  of  the  anatomical 
lesions  above  described  may  give  rise  to  special  symptoms.  If  the  mesenteric 
glands  are  involved,  they  can  sometimes  be  felt  through  the  boat-shaped  abdo- 
men, and  there  is  exhausting  diarrhoia.  The  child  becomes  pale,  thin,  and 
hollow-eyed,  the  hair  falls  out,  and  the  skin  is  dry  and  thin.  There  is  often 
retarded  mental  develoj)ment.     Females  frequently  have  leucorrhoea. 

In  many  cases  the  evidences  of  scrofula  remain  latent  until  evoked  by  some 
trivial  excitation,  as  a  slight  bruise  on  a  joint,  which  results  in  inflammation, 
swelling,  hydrarthrosis,  and  final  disintegration  of  the  entire  structure;  or  a 
spot  of  facial  eczema  may  spread  to  the  conjunctiva,  and  finally  excite  ojihthal- 
niia,  with  permanent  im])airment  of  vision;  or  a  simple  bronchitis  ends  in 
catarrhal  pneumonia,  with  various  accompanying  symptoms  of  scrofula. 

Course  and  Duration. — The  duration  of  the  affection  depends  largely 
on  the  ability  of  the  parents  to  secure  proper  surroundings  and  treatment  for 
the  child.  Advanced  cases  yield  very  slowly  to  treatment  even  under  the 
best  conditions.  There  is  often  periodic  improvement,  followed  by  exacerba- 
tion of  the  syni|itoms.  The  same  symptoms  may  recur  again  and  again,  and 
new  lesions  will  develop  while  old  ones  disappear.  After  puberty  the  scrofu- 
lous diathesis  tends  to  disappear. 

Terminations  and  Complications. — The  majority  of  scrofulous  cases 
recover  completely,  and  the  catarrhs  and  cutaneous  eruptions  are  amenable  to 
treatment.  When  the  bones  and  joints  are  extensively  involved,  with  necroses, 
abscesses,  and  fistulas,  the  prolonged  sup])uration  is  apt  to  engender  amyloid 
visceral  disease,  which  eventually  proves  fatal.  This  occurs  in  the  kidney, 
liver,  or  spleen.  Enlarged  bronchial  glands  may  sui>purate  and  ulcerate  into 
the  bronchi,  and  death  may  result  from  pneumonia.  luflauimation  of  the 
mesenteric  glands,  accomj)anied  by  chronic  intestinal  catarrh  and  diarrlirea, 
<-auses  death  in  vonug  children  more  frequently  than  any  other  scrofu- 
lous condition.  A  less  frcfpient  but  often  fiital  termination  is  catarrh  of 
the  middle  ear,  when  it  involves  the  m.astoid  cells  and  the  inflammation 
extends  to  the  meninges  of  the  brain.  The  various  scrofidous  diseases  «»i'  the 
bones  and   joints  may  result  in  pcriiiMucul  ankylosis  or  other  disfigurement. 

Scrofula  so  weakens  the  system  that  sev(>re  iuterciirniit  diseases  arc  nnich 
more  fatal  when  thev  occur  in  connection  with  it  than  they  are  in  a  previously 
liealthv  person,  aixl  all  accomj)anying  morbid  processes  retrograde  very  slowly. 
Scrofulous  children  niavdie  Croni  croiq»,  hydrocephalus,  intestinal  tiii.ercidosis, 
or  acute  miliarv  tidxTi'idosis. 


342  SCROFULA. 

Diagnosis. — In  typical  cases  scrofula  is  easily  identified.  Separate  lesions 
of  the  skin  or  bones,  etc.  may  give  rise  to  some  doubt  as  to  whether  they  are 
of  scrofulous  origin  or  are  due  to  some  other  cause.  In  such  instances  the 
diagnosis  of  scrofula  can  usually  be  made  from  a  careful  study  of  the  history 
of  the  patient  and  from  the  extremely  chronic  character  of  the  inflammation 
and  its  slow  development,  the  tendency  to  cell-proliferation  and  to  caseation 
of  lymphatic  glands. 

Congenital  or  acquired  syphilis  may  be  confounded  with  scrofula.  In 
hereditary  syphilis  the  lesions  appear  either  at  birth  or  much  earlier  than  they 
do  in  scrofula,  and,  moreover,  a  history  of  syphilis  is  usually  obtainable,  and 
the  disease  yields  promptly  to  mercury  and  potassium  iodide. 

Prog-nosis. — The  prognosis  is  favorable  when  the  patient  is  seen  early,  and 
when  he  can  at  once  be  placed  under  projier  hygienic  regimen  and  dietetic  treat- 
ment. The  })rognosis  is  less  favorable  when  the  hereditary  factors  are  strongly 
marked,  and  when  the  bones  and  joints  or  the  bronchial  and  mesenteric  glands 
are  severely  involved.  In  bad  cases  there  is  present  a  liability  to  miliary 
tuberculosis. 

Treatment. — The  treatment  comprises  (1)  prophylaxis;  (2)  hygiene;  (3) 
dietetic  and  (4)  tonic  measures  ;  (5)  the  control  of  the  local  inflammations. 

(1)  Prophylaxis. — The  ideal  prophylaxis  would  include  the  prevention  of 
marriage  among  all  persons  who  are  tubercular,  scrofulous,  or  actively  syph- 
ilitic, who  are  suffering  from  wasting  cachexias  or  malignant  disease,  and 
among  those  whose  age  or  consanguinity  makes  them  unlikely  to  beget  healthy 
offspring.  Such  extreme  measures  are  obviously  unattainable.  It  is  possible, 
however,  to  do  much  for  the  children  of  these  parents.  An  infant  born  with 
such  heritage,  whether  appearing  scrofulous  or  not,  should  not  be  nursed  by 
its  feeble,  anaemic  mother,  but  should  have  a  visrorous,  wet-nurse.  Failino- 
this,  it  must  be  fed  on  the  best  of  cow's  milk,  avoiding  artificial  foods. 
Unusual  care  must  be  taken  at  all  times  to  secure  an  abundant  supply  of  pure 
fresh  air,  with  proper  personal  cleanliness  and  warm  clothing.  A  child  with 
enlarged  lymphatic  glands  should  be  protected  with  great  care  from  taking 
cold  and  from  irritation  which  may  establish  chronic  catarrhs.  Enlarged  ton- 
sils should  be  excised.  By  giving  careful  attention  to  the  details  which  follow 
many  weak  infants  may  be  successfully  carried  through  the  period  of  greatest 
liability  to  scrofulous  manifestations — namely,  that  which  lies  between  the 
second  and  fom-teenth  years. 

(2)  Hyr/ienu-  Treatment. — Scrofulous  children  should  be  kept  in  the  open 
air  as  nnich  as  ])()sslble,  and  hence  country  life  is  best  for  them.  They 
improve  either  among  the  mountains  or  at  the  seashore.  Children  having 
glandular  enlargement  are  said  to  do  better  at  the  seaside  than  those  who  are 
eczematous  (Bergeron),  Sea-bathing  is  particularly  beneficial  in  the  former 
cases.  It  has  been  found  in  asylums  and  hospitals  that  children  may  become 
scrofulous  even  with  proper  diet  and  cleanliness,  provided  the  air  be  damp, 
close,  and  impure.  Special  pains  should  be  taken  to  keep  the  bowels  in  reg- 
ular action,  and  to  maintain   the  functions  of  the  skin  by  clothing  of  proper 


TRI'JATMENT.  343 

warmth  and   nnirritating  toxturo,  and  by  cold  baths  for  tho   stronger  children 
or  tepid  sponge-baths  for  the  feeble  ones. 

Older  children  shoidd  not  be  allowed  to  overtax  their  enerov  in  stndv  or 
confining  work  of  any  kind,  and  plenty  of  sleep  is  important.  AVell-reg- 
nlated  exercise  in  tho  open  air  should  be  taken  daily  ;  in  very  feeble  cases 
massase  is  of  service. 

(3)  Dietetic  Treatment. — The  diet  should  bo  simple  and  nutritions,  and 
must  contain  a  large  proportion  of  nitrogenous  food.  It  is  common  for  tlie 
poor  to  feed  their  scrofulous  children  on  bulky,  starchy  food — {potatoes,  etc. — 
which  is  not  in  itself  injurious,  but,  by  reason  of  its  large  voliniie  in  jiro))or- 
tion  to  its  nutritive  value,  overtaxes  the  enteebled  digestive  powers.  This 
error  should  be  corrected,  when  possible,  by  substituting  a  portion  of  milk, 
eggs,  or  meat  in  the  diet. 

(4)  Tonic  Treatment. — The  use  of  cod-liver  oil  for  scrofulous  affections  has 
long  proved  so  benefieial  that  it  has  been  regarded  by  some  as  a  specific.  It 
is,  however,  simply  a  readily  assimilable  form  of  fatty  food,  and  as  such  it 
proves  of  great  value  when  pro])erly  administered.  It  is  far  more  useful,  as 
a  rule,  in  the  erethitic  than  in  the  tori)i(l  type.  From  1  to  2  drachms  should 
he  given  to  children  two  or  three  times  daily,  an  hour  after  meals;  and  because 
it  must  be  continued  for  a  long  period,  it  is  well  to  suspend  its  exhibition  once 
a  month  for  ten  days,  in  order  to  prevent  it  from  disgusting  the  patient. 
When  it  j)rovokes  decided  distaste,  the  dose  will  often  be  taken  with  the 
promise  of  a  pep])ermint  lozenge  to  follow.  The  oil  should  be  omitted  in 
very  hot  weather.  In  simple  eases,  when  possible,  it  is  best  to  give  the  pure 
oil  :  otherwise,  a  carefully  prepared  emulsion  with  })hosphates  may  be  sub- 
stituted. Iron,  arsenic,  and  iodide  of  potassium  are  the  other  tonics  whicli 
prove  of  most  value,  and  the  latter  is  particularly  beneficial  when  glandular 
liyperplasia  is  prominent.  The  syrup  of  the  iodide  of  iron  is  a  very  usi'tul 
tonic  for  voung  scrofulous  children,  in  doses  of  from  10  to  30  minims  two  or 
three  times  a  dav,  well  diluted.  Pure  beechwood  creasote  in  doses  of  one- 
(piarter  or  one-half  of  a  drop  three  times  daily,  given  in  milk,  is  favorably 
recommended  by  Forchheimer,  presumably  upon  the  theory  of  the  tubercular 
origin  of  the  scrofulous  condition,  which  is  strongly  advocateil  by  him.  Sul- 
phide of  calcium  is  believed  by  some  to  exert  a  beneficial  influence  upon  the 
patient's  general   con<lition,   and   especially    upon    glanduhu-    enlargement   ..r 

suppuration. 

(5)  Treatment  of  the  Lifldiniiudorij  and  Other  St/mj)tnms. — W'\\vu  I  he  bones  i.r 
joints  are  implicated  it  is  useful  to  add  lactoi)hospliates  or  hypophosphites  of 
iime  and  sodium  to  the  cod-liver  oil.  These  hyiK.phosphites,  as  well  as  bicarbuu- 
ates  of  sodium  or  potassium,  are  to  be  given  when  glandidar  eidargemeut  exists  ; 
and  their  utility  has  been  referred  to  the  asserted  deliciency  of  alkalies  in  the 

blood. 

The  details  of  local  trcatuieut  uf  I  lie  diseased  bones  and  joints  belong  to  sur- 
gery, and  of  the  various  ec/XMiiatous  disorders  to  dermatology. 

The  enlarged  glands  are  not    iniieli  l.enedled   by  h.cal  iiijection,  inunction, 


344  SCROFULA. 

or   applications    of  iodine,    iodoform,    or   other    remedies.     If  they    become  | 

inflamed  or  if  painful  and  suppurating,  they  should  be  poulticed  and  incised, 
for  if  left  to  suppurate  and  open  of  themselves,  they  leave  very  ugly  stellate 
cicatrices  and  fistulse.  If  general  improvement  in  the  patient's  condition  and 
removal  of  local  sources  of  irritation,  such  as  carious  teeth,  catarrhs,  etc.,  are 
not  followed  by  reduction  in  size  of  the  glands,  and  if  they  are  unsightly  or 
increase  in  size,  it  is  well  to  extirpate  them.  Sometimes  they  are  removed  by 
the  scoop,  but  as  they  are  apt  to  soften  irregularly,  and  not  uniformly,  it  is 
best  to  completely  excise  them  by  the  knife.  So  long  as  they  remain  there  is 
a  risk,  though  a  moderate  one,  of  their  breaking  down  and  serving  as  foci  for 
general  distribution  of  pus  or  caseous  material  in  the  system. 

Summary  of  Treatment. — Good  hygiene;  abundant  and  largely  nitrogenous 
diet;  tonics,  such  as  cod-liver  oil,  lime  salts,  and  iodides;  surgical  measures 
for  the  bone  and  joint  complications. 


SYPHILIS. 

By  W.  oilman  THOMPSON. 


Definition. — Syphilis  is  a  chronic  infectious  disease,  communicated  only 
bv  inoculation.  It  is  characterized  by  an  initial  lesion  of  the  mucous  mem- 
brane or  skin,  accompanied  by  glandular  enlargement  and  followed  by  a  great 
variety  of  chronic  lesions,  the  most  typical  of  which  is  the  gunmia. 

Synonyms. — Lues  venerea ;  Lustseuche  (Ger.) ;  Mai  venerien  (Fr.) ; 
the    Pox. 

Certain  authors,  as  Hutchinson,  class  syphilis  with  the  exanthemata,  since 
it  exhibits  a  period  of  incubation,  of  exacerbation,  of  remission,  and  of  relapse 
in  its  final  or  tertiary  stage.  There  are  peculiar  facts  which  are  in  accord 
with  this  view,  but  the  types  of  the  disease  and  its  lesions  are  so  numerous 
and  varied  that  by  a  majority  of  writers  it  is  classed  by  itself. 

The  type  of  syphilis  may  be  benign  or  malignant  or  exhibit  any  inter- 
mediate grade  of  severity.  It  is  almost  always  chronic,  and  only  exceptionally 
acute  if  very  malignant. 

Etiology. — Syphilis  is  either  acquired  or  inherited.  The  latter  form  is 
far  less  frequent  than  the  former,  and  it  will  be  separately  considered. 
(  Vide  infra.) 

Acquired  Syphilis  is  transmitted  by  inoculation  through  the  agency  of 
the  discharges  proceeding  from  any  of  the  earlier  lesions  of  the  disease.  It  is 
thus  communicated  to  a  previously  healthy  person  through  an  abraded  surface 
of  skin  or  mucous  membrane.  It  is  ordinarily  ac(|uired  during  sexual  inter- 
course through  very  slight  abrasions  of  the  mucous  surface  of  the  genitalia, 
and  possibly  by  direct  absorption  where  the  surface  is  delicate,  as  it  is  over  the 
|)repuce  and  glans  penis. 

Since  the  propagation  of  syphilis  is  not  necessarily  confined  to  venereal 
acts,  it  is  convenient  to  speak  of  genital  syphilis  in  distinction  from  extra- 
genital syphilis,  referring  solely  to  the  mode  of  ac(|uisition  of  the  primary 
lesion.  Thus,  instruments  carelessly  used  about  the  throat  or  mouth  of  a 
syphilitic  subject,  infected  razors,  pipes,  driidving  vessels  or  eating  utensils, 
the  operation  of  tattooing,  direct  vaccination  (especially  if  llic  pu>tiilc  contain 
blood),  or  kissing  with  cliap|)c<l  or  cracked  lips, — iuc  all  ukuv  or  less  common 
agencies  in  tin;  transmission  of  the  virus  from  llic  infected  to  the  healthy. 

Syphilis  which  occurs  in  young  children  who  h:ivc  lived  :iiiioiim  ndidts 
afU'cted   with    llic  disease  is  (jiiite  as  a|»t  to   be  :ic<jiiired   as   Ik •re(htary. 

A    hc:iltli\-  iiiotlier   iiiav  be   iiioeuhited    l.y  her  own  child,  who  has  :ie(|nired 

the  disease   (Voin   an    inllcted    nur.-e. 

345 


34t)  SYPHILIS. 

It  is  not  possible  to  reinoeiilate  a  person  with  syphilitic  virus  if  he  is 
already  under  the  constitutional  influence  of  the  disease,  and  it  is  very  rare  to 
have  more  than  a  single  point  of  original  inoculation. 

The  period  of  viability  of  the  syphilitic  virus  is  not  known,  but  it  is  sup- 
posed to  retain  its  virulence  for  months,  if  not  longer,  when  removed  from  the 
body.  Syphilis  can  be  inoculated  directly  from  the  blood  or  from  the  secre- 
tions of  sores,  mucous  patches,  etc.  of  patients  who  are  in  the  early  stages  of 
the  disease.  Epidemics  have  several  times  been  caused  by  syphilitic  mid- 
wives  inoculating  a  number  of  mothers,  who  in  turn  have  inoculated  their  own 
children  and  husbands. 

The  Bacillus. — The  most  recent  view  of  the  cause  of  syphilis,  and  the 
theory  which  is  gaining  many  converts,  is  that  it  is  due  to  a  micro-organism. 
Klebs,  Birch-Hirschfeld,  Lustgarten,  and  others  have  described  a  bacillus  found 
in  various  syphilitic  lesions.  In  1884,  Lustgarten  described  the  bacillus  of 
syphilis  as  being  smaller  than  the  bacillus  tuberculosis,  and  occurring  in 
curved  or  straight  forms,  singly,  in  pairs,  or  in  little  groups  or  chains,  but  not 
in  rods.  The  length  is  from  two  to  seven  thousandths  of  a  millimetre,  and 
the  width  is  about  three  ten-thousandths.  It  is  believed  to  possess  spores. 
It  is  not  found  free,  but  is  contained  in  round  cells.  Klemperer  and  other 
observers  have  verified  the  existence  of  this  bacillus,  and  it  is  believed  by 
many  that  it  constitutes  the  active  agent  in  the  propagation  of  syphilis.  This 
germ  is  found  in  the  excretions  of  syphilitic  sores  and  in  some  gummata  and 
condylomata. 

It  may  be  possible  that  the  constitutional  symptoms  are  caused  by  products 
developed  by  the  action  of  the  germ  in  the  tissues  with  which  it  is  in  contact, 
as  in  the  case  of  di))htheria,  typhoid  fever,  and  other  diseases  ;  but  further 
research  is  required  before  this  theory  can  be  regarded  as  established.  Inoc- 
ulation and  cultivation  tests  made  with  the  bacillus  of  syjihilis  have  not  yet 
proved  as  convincing  as  they  have  with  other  bacilli,  and  therefore  the  belief 
in  the  causative  relation  of  the  germ  to  the  disease  is  at  })resent  based  chiefly 
upon  analogy,  but  there  is  very  reasonable  ground  for  its  acceptance. 

It  is  doubtful  whether  true  syphilis  exists  among  the  lower  animals.  It  is 
said  to  have  been  inoculated  successfully  from  man  into  rabbits  and  apes. 

iJidribution. — Syphilis  occiu's  in  all  parts  of  the  civilized  world  and 
among  many  savage  nations.  In  past  centuries  it  is  said  to  have  been  epi- 
demic and  very  malignant.  Among  civilized  people  the  disease  is  so  much 
better  understood,  and  so  much  better  treated  than  formerly,  that  upon  the 
whole  it  is  becoming  milder.  It  is  common  among  soldiers  and  sailors,  and 
is  carried  by  them  especially  to  garrison  and  seaport  towns  and  cities.  Its 
spread  is  effected  almost  exclusively  by  existing  social  conditions  ;  hence  it  is 
comparatively  infrequent  in  rural  districts,  but  common  in  cities  or  wherever 
overcrowding  and  poverty  combine  to  favor  lax  morality  among  the  sexes. 

Park  declares  that  he  has  encountered  syphilis  among  the  natives  in  parts 
of  Africa  never  before  visited  by  any  white  man  or  Arab ;  and  that  the  Mon- 
buttu  and  Bari  tribes  in  the  Equatorial  Province  inoculcate  with  syphilitic  virus, 


GENERAL    DESCRIPTIOX.  347 

with  the  result  that  a  rash  and  other  familiar  syni])toms  soon  appear,  but  the 
course  of  the  disease  seems  to  be  favorably  nuxliHed. 

Apparently  every  race  is  susceptible  to  inoculation,  and  individual  ininni- 
nitv  is  certainlv  verv  rare.  When  svi)hilis  is  introduced  aiuonsr  new  races,  as 
it  was  conveyed  by  Europeans  to  the  native  Sandwich  Islanders,  it  works  great 
havoc.  Among  the  Chinese  the  disease  is  apparently  more  virident  than  it  is 
with  other  races,  at  least  when  it  is  contracted  from  them  by  sailors. 

General  Description. — The  lesions  of  syphilis,  as  well  as  its  clinical 
history,  are  divided  into  three  stages  or  periods,  called  respectively  the  pri- 
mary, secondary,  and  tertiary.  While  this  division  is  of  value  in  the  descrip- 
tion of  the  disease,  it  must  be  stated  that  in  actual  practice  it  is  found  that 
wide  variations  occur,  the  symptoms  of  one  period  occurring  \\\x\\  those  of 
another  with  great  frequency. 

Tlie  primary  period  is  that  of  local  manifestation,  characterized  by  the 
appearance  and  development  of  the  "  initial  lesion  "  or  *'  chancre,"  a  sore  pro- 
duced by  inoculation,  with  accomj>auying  enlargement  of  neighboring  lymphatic 
glands.  This  ])eriod  lasts  for  about  six  weeks  on  the  average.  It  is  also  some- 
times designated  as  the  "  incubation  stage  "  of  the  secondary  period. 

All  acquired  sy))hilis  is  believed  to  originate  with  a  chancre.  When  none 
is  found,  it  has  either  eluded  observation  or  it  has  been  slight  and  has  healed 
before  examination  was  made  for  it.  Occasionally  it  cscai)es  detection  by 
occurring  within  tlie  urethra. 

The  secondary  period  is  characterized  by  the  development  of  general  (M- 
constitutional  svmptoms,  particularly  a  diffuse  roseola  and  the  "  nuicous})atch." 
It  lasts  for  a  varying  length  of  time,  from  two  months  \\\)  to  two  or  three 
years.  As  a  general  rule,  the  secondary  syin]»t()ms  and  lesions  have  disap- 
peared at  tlie  end  of  the  second  year.  This  period  embraces  the  mild  and 
earlier  lesions  of  the  mucous  membranes  and  skin,  and  some  of  those  of  the 
viscera  and   nerves. 

It  is  often  verv  difficult  to  draw  a  strict  line  of  (Icmarcatioii  between  the 
lesions  of  the  second  and  third  stages,  and,  moreover,  the  secondary  eruption 
frequently  appears  before  the  primary  sore  is  cicatrized.  There  may  be  a 
latent  period  of  several  months  or  many  years  l)etweeii  the  (lisa|)i)earanei' 
of  the  secondary  and   the  beginning  of  the  tertiary  le-ioiis,  or  the  two  periods 

may  overlap. 

The  tertiary  period  commonly  commences  between  the  third  and  .-ixth 
years,  although  there  are  wide  dei)artures  on  both  sides  of  these  limits.  It 
is  characterized  by  the  development  of  inflammatory  growths  called  "gum- 
mata,"  and  by  a  great  variety  of  visceral,  cutaneous,  mucous,  and  nerve  lesions. 

Its  duration   is  influenced  by  treatment,  i)ut  it    may  ia>t    fr- ne  ..r  tw..  to 

twenty  years  or  more,  and  the  lesions,  once  formed,  may  outla>t   th.'  activity 

of  the  disease. 

The  lesions  of  the  second  stage  are  often  syiiunefrically  disposed  on  both 
sides  of  the  bc.dy,  but   the  tertiary  lesiims  are  noted    for  their  asynnuetry. 

While  syphilis  is  inoculable  during  the  first  an<l  second  |)eriods,  thclcrdary 


348  SYPHILIS. 

form  is  non-iufectious,  as  a  rule,  althongli  Fournier  and  other  experienced 
observers  have  seen  cases  of  transmission  of  the  tertiary  disease. 

Morbid  Anatomy. — In  general  the  morbid  jjrocesses  of  syphilis  are  charac- 
terized far  more  by  cell-proliferation  than  by  pus-formation. 

The  morbid  changes  resulting  in  any  form  of  syphilis  may  be  peculiar  to 
the  disease  or  they  may  be  common  to  other  diseases,  and  yet  when  they  occur 
in  syphilis  they  elect  a  peculiar  site  and  distribution,  as  is  the  case  with  many 
cutaneous  eruptions.  The  more  that  congestive  or  inflammatory  ])rocesses 
characterize  a  lesion — that  is,  the  more  active  they  are — the  less  special  or 
peculiar  will  that  lesion  become,  because  new  tissue  requires  time  for  its 
formation  (Gowers). 

The  chief  varieties  of  syphilitic  lesions  may  be  grouped  under  the  general 
terms  of  inflammation  and  tissue- formation.  The  former  develops  early,  as, 
for  example,  roseola  and  certain  other  skin  affections.  The  latter  appears 
much  later,  in  the  growths  which  are  termed  gummata,  etc.  A  variety  of 
non-typical  inflammations  may  arise  in  the  course  of  syphilitic  disease,  but  there 
is  only  one  growth,  the  gumma,  which  is  in  any  degree  characteristic. 

The  lesions  present,  as  stated,  wide  variation  in  the  time  of  their  appear- 
ance, but  they  are  here  considered  in  the  order  in  which  they  are  most  fre- 
quently observed. 

Lesions  of  the  Three  Periods. — The  typical  chancre,  called  also  the 
"  initial  lesion,"  "  hard  "  or  "  Hunterian  chancre,"  is  developed  at  the  site  of 
inoculation  on  the  al)raded  mucous  membrane  or  skin,  and  characterized  by 
hypersemia  and  cellular  infiltration,  which  are  followed  by  an  ulcerating  papule 
or  a  shallow,  indolent  ulcer.  It  is  usually  quite  small,  being  about  the  size  of 
a  split  pea,  but  it  may  become  considerably  larger.  It  feels  hard  to  the  touch, 
and  presents  a  circumscribed  induration  from  infiltration  of  cells  around  its 
base.  It  is  of  a  dark-reddish  hue,  and  is  coated  by  a  glairy,  viscid,  thin  secre- 
tion, presenting  a  glazed  aspect.  It  is  further  characterized  by  the  absence  of 
irritation  and  of  the  formation  of  pus. 

The  appearance  of  the  chancre  will  vary  with  its  site.  Chancres  of  the 
lips,  prej)uce,  labia  majora,  or  scrotum  exhibit  extended  induration,  and  one 
can  readily  isolate  them  by  manipulation  ;  but  on  the  glans  penis,  cervix,  or 
where  the  surface  is  firmly  bound  there  is  much  less  hardness.  The  explana- 
tion of  this  fact  is  that  in  loose  connective  tissue  the  cellular  infiltration  readily 
extends  without  compressing  the  blood-vessels,  but  where  the  connective  tissue 
is  very  scanty  the  chancre,  deprived  of  nutrition,  readily  ulcerates  without  the 
occurrence  of  much  induration. 

Sometimes  the  lesion  becomes  papular  or  it  is  large  and  flat,  or  a  large 
sore  upon  the  lip  may  resemble  epithelioma.  Quite  exceptionally  it  develops 
into  a  warty  growth. 

The  most  frequent  site  for  chancre  in  the  male  subject  is  on  the  prepuce  or  at 
the  base  or  surface  of  the  glans  penis.  It  may  occur  at  the  external  urethral  mea- 
tus or,  exceptionally,  within  the  urethra.  In  females  it  is  more  frequently  found 
upon  the  labia  or  at  the  posterior  commissure  than  deep  within  the  vagina. 


MORBID    ANATOMY.  349 

Next  to  the  genitalia,  the  mo.st  frequent  sites  I'ur  the  primary  lesion  arc 
the  parts  about  the  head,  nioutii,  and  throat,  and  the  hands.  Cephalic  chan- 
cres have  about  the  same  average  duration  as  those  of  the  genitalia. 

The  initial  lesion,  subjected  to  irritation  from  clothing,  coition,  etc.,  may 
become  greatly  inflamed.  Pus  forms  and  an  extensive  slough  follows,  which 
may  be  phagedtenic  or  even  gangrenous.  This  is  more  liable  to  occur  in  per- 
sons possessing  a  predisposition  to  suppuration  from  any  cause,  and  in  those 
addicted  to  alcoholic  and  venereal  excesses. 

In  case  of  a  very  moderate  degree  of  primary  erosion  with  no  induration 
the  glands  are  but  slightly  swollen,  but  sometimes  the  erosion  may  be  over- 
looked, and  the  intumescence  of  the  glands  is  then  the  only  symptom  of  the 
primary  stage.  In  many  cases  the  initial  sclerosis  results  in  a  ridge  or  plaque 
or  nodule,  which  persists  into  the  secondary  period. 

A  certain  amount  of  lymphatic  adenitis  follows  every  syphilitic  inoculation, 
for  the  virus  finds  its  way  to  the  general  circulation  through  the  lymph-glands. 
It  commences  from  the  eighth  to  the  fourteenth  day  after  the  chancre  appears, 
and  lingers  for  at  least  six  or  seven  weeks,  or  through  the  period  of  secondary 
incubation.  Extra-genital  initial  lesions  are  often  accompanied  by  consider- 
able glandular  enlargement. 

The  degree  of  enlargement  frequently,  but  not  always,  is  commensurate 
with  the  extent  of  the  chancre,  and  it  appears  synchronously  with  the  indura- 
tion about  the  primary  sore.  It  occurs  usually  in  those  glands  situated  nean>.<t 
to  the  site  of  the  primary  lesion,  and  upon  the  same  side  with  it.  Thus  with 
genital  chancre  the  glands  first  affected  are  the  inguinal,  and  in  oral  chancre 
they  are  the  glands  of  the  neck  and  angle  of  the  jaw.  There  are  exceptions 
to  this  rule,  however,  and  sometimes  glands  on  the  opposite  side  of  the  body 
become  first  hypertrophied.  Moreover,  a  chancre  on  the  median  line  is  not 
always  followed  by  a  bilateral  glandular  enlargement.  At  first  one  gland 
becomes  much  more  prominent  than  the  rest,  and  the  size  varies  from  a  bean 
to  a  small  hen's  egg.  After  some  time  the  glands  on  the  opposite  side,  corre- 
sponding to  those  first  affected,  begin  to  enlarge.  The  extent  of  the  aden- 
opathy will  depend  on  the  number  of  glands  with  which  the  lymjvhatic  vessels 
in  the  vicinity  of  the  primary  sore  happen  to  commiuiicate.  The  glands  when 
first  involved  are  humid  and  engorged,  but  seldom  extensively  indurated. 

If  the  periglandular  tissue  becomes  iuHamed,  as  it  occasionally  does, 
especially  in  the  cervical  region  from  the  motion  of  the  jaws  and  neck,  it  is 
difficult  to  identify  the  separate  glands,  which  are  obscured  in  a  general 
tumefaction. 

When  suppuration  takes  place  in  the  glands,  the  ])rocess  is  ajtl  (<•  be  -lower 
than  it  is  in  non-specific  inflammations.  Occasionally  all  tiie  perijihcral 
lymph-glands  in  the  body  are  swollen  simultaneously.  This  universal  enlarge- 
ment of  the  accessible  lyniphatic  glands  is  of  much  service  in  courirming  an 
otherwise  doubtful  diagnosis  of  past  syi)hilitic  infection.  Those  chicily  iiivrsti- 
gated  arc  the  epitnu-hlear  gland  and  tiie  mciubcrs  of  the  cervical  chains. 

The  mucous  patch  is  a  lesion  of  (he  secondary  period  of  syjihilis.      It  is 


350  SYPHILIS. 

found  on  the  mucous  membranes  or  the  skin  about  the  mouth  or  anus,  espe- 
cially where  the  skin  becomes  continuous  with  the  mucous  membrane.  Such 
lesions  may  occur  singly  or  several  may  appear  at  once.  The  patches  have  a 
fairly  uniform  oval  or  rounded  contour  ;  they  are  slightly  raised  above  the  sur- 
rounding healthy  tissue ;  they  are  easily  excoriated,  but  are  not  invariably 
ulcerated,  although  they  usually  are  so.  They  then  become  moist,  and  they 
are  covered  by  a  grayish  film.  They  are  not  commonly  painful  to  the  touch, 
and  often  escape  observation  by  the  patient ;  but  in  the  mouth  they  are  irri- 
tated by  salt  or  pepper.  When  they  involve  the  skin,  there  is  cellular  infil- 
tration of  the  cutis  and  the  papillae  are  enlarged.  In  size  they  vary  from 
that  of  a  small  pin's  head  to  an  inch  or  more  in  diameter,  and  several  of 
them  may  coalesce  into  one  large  sore.  There  are  more  or  less  induration 
and  thickening  about  their  periphery.  In  females  mucous  patches  occur 
more  regularly  than  exanthems. 

Ulceration  may  take  place  in  the  mucous  membrane  of  the  oesophagus, 
rectum,  trachea,  or  bronchi.  Sometimes  the  soft  palate  becomes  so  eroded  as 
to  entirely  disappear,  or  a  perforating  ulcer  may  eat  out  its  base  and  leave  it 
suspended  by  two  lateral  bands.  There  may  be  similar  destruction  of  the 
epiglottis  and  vocal  cords. 

The  mucous  patch  heals  over  completely  in  from  six  to  ten  weeks,  leaving 
a  glistening  cicatrix  if  it  was  deeply  ulcerated  ;  otherwise  there  is  no  trace 
left.  Men  who  smoke  are  particularly  apt  to  have  these  patches  develop  in 
the  mouth,  on  account  of  the  local  irritation  produced  by  hot  tobacco-fumes. 
M^hen  situated  between  two  opposing  surfaces  like  the  buttocks,  where  there  is 
much  friction,  the  patches  may  vegetate  into  condylomata. 

Other  lesions  of  the  secondary  period,  including  various  cutaneous  erup- 
tions, inflammations  of  the  eye,  etc.,  will  be  briefly  referred  to  in  connection 
with  the  symptomatology  of  the  period.  For  a  more  detailed  account  of 
them  the  reader  must  be  referred  to  special  works  upon  syphilis,  dermatology, 
or  ophthalmology. 

The  lesions  which  arise  during  the  tertiary  period  may  eventually  affect 
any  organ  of  the  body.  Their  extent  is  often  quite  independent  of  the  inten- 
sity of  the  primary  sore  or  of  the  secondary  symptoms  and  lesions.  They 
embrace  the  formation  of  gummata,  syphilides,  and  various  degenerative  and 
necrotic  processes.  They  are  not  symmetrically  situated,  like  the  secondary 
lesions.  Tiiey  are  amenable  to  treatment,  but  recur  if  the  treatment  be  with- 
held. They  are  not  accompanied  by  pyrexia  or  by  cachexia,  as  a  rule, 
although  marked  anaemia  and  a  lack  of  mental  and  bodily  energy  may  be 
observed. 

Wiien  tertiary  lesions  develop  early,  they  are  explained  by  the  excessive 
celhiiar  proliferation,  which  chokes  the  lymphatic  vessels,  invades  and  thickens 
their  walls,  and  prevents  the  jiroper  removal  of  waste  material  (White). 

Gummata  are  sometimes  described  as  "gummy  tumors,"  but  they  are 
essentially  inflammatory  products  originating  in  the  connective-tissue  struc- 
tures of  membranes,  viscera,  skin,  periosteum,  etc. 


3I0RIUD    AXATOMV.  351 

(TuniiiKita  are  cither  isolated  and  distinctly  circumscribed,  or  else  they  may 
be  diffused  throughout  the  affected  tissue,  infiltrating  rather  tiian  supplanting  it. 
To  the  unaidetl  eye  they  appear  as  nodules,  varying  in  size  from  a  pin's  head 
to  a  hen's  egg,  which  are  either  soft  or  firm,  of  a  gray  color,  anil  translucent 
or  opaque.  The  inflammation  may  be  quite  acute,  with  considerable  swelling 
and  congestion  of  the  affected  region,  but  it  is  more  often  chronic. 

The  inflannnatory  products,  consisting  of  small,  irregular  or  round  cells, 
with  a  soft  gelatinous  basement  substance,  may  be  diffusely  spread  throughout 
a  viscus,  but  frequently  they  are  collected  in  a  limited  area,  forming  a  distinct 
mass  or  "gummy  tumor,"  which  either  remains  for  some  time  without  change 
or  is  absorbed,  or  more  often  it  advances  to  the  stage  of  cheesy  tlegeneration, 
or  it  is  converted  into  fibrous  tissue  or  into  a  suppurating  mass. 

The  gumma  has  no  true  capsule,  but  it  may  be  enveloped  in  granulation 
and  fibrous  tissue,  which  contracts. 

Much  of  the  tissue-formation  as  observed  in  syphilis  is  very  similar  to  that 
accompanying  ordinary  inflammatory  action,  but  there  is  a  common  tendency 
for  caseation  to  supervene  and  for  contracting  fibrous  tissue  to  form  cicatrices. 
As  a  rule,  the  lesions  of  the  skin,  mucous  membranes,  bones,  and  cartilages 
produce  ulceration  and  extensive  sloughing,  but  the  deeper  visceral  lesions 
residt  in  the  formation  of  gummy,  caseous,  or  calcareous  masses.  The  gum- 
mata,  when  thev  do  occur  in  the  skin  or  mucous  membranes,  may  be  very 
destructive  through  resulting  ulceration  and  extensive  cicatrization.  In  this 
manner  the  tonsils,  soft  palate,  and  nose  may  be  destroyed.  Cicatrices  of  the 
mucous  membranes  may  by  contracting  cause  ultimate  stricture.  The  traces 
of  former  gummata  in  tlie  various  viscera  of  the  body  are  often  visible  in 
irregular,  depressed,  frequently  star-shaped   cicatrices. 

The  gummata  may  be  slowly  absorbed  without  appearing  at  the  surface. 
In  this  case  the  skin  is  left  thinned  and  sunken  over  the  site  of  the  gumma. 

Syphilidc.s. — The  tertiary  syi)hilides  are  polymorphic  ;  that  is,  several 
.  varieties  may  be  found  simultaneously,  as  in  the  secondary  period.  They  arc 
apt  to  form  in  circular  spots  or  crescents.  Tiiey  are  especially  prone  to  develop 
where  there  is  local  irritation  or  friction  of  the  surface.  They  are  not  charac- 
terized by  accompanying  pyrexia.  ^lany  are  of  the  papular  type  and  seldom 
cicatrize  under  the  use  of  mercury  ;  others  aflect  the  tissues  much  mor(>  deeply 
than  the  skin  lesions  of  the  secondary  stage,  and  ulcerate,  leaving  ugly 
depressed  scars.  They  are  usually  fewer  in  number  than  the  secondary 
svphilides,  but  are  more  apt  to  coalesce.  When  scaly  the  scales  are  seldom 
lustrous  or  verv  abundant.  For  a  detailed  account  of  the  great  variety  of 
tertiary  syphilodermata  the  nadcr  is  referred  to  special  works  upon  sypliilis.) 
Partial  loss  of  hair  and  teeth  is  of  coiunion  occurrcuce. 

Visceral  Lesions. — The  subjects  ol"  vixcral  or  internal  sy|)liilis  of  llic 
vari-.us  or.raus,  such  as  the  brain,  cranial  nerves  and  spinal  con),  the  liver, 
kidneys,  spleen,  and  aneiirisnw;  .,1"  syphiliti<- origin,  will  Ix"  treated  in  piuper 
detail"  in  this  work  under  tin-  i—peetive  titles  of  the  diseases  of  the  varimis 
organs.     These  lesions  are  <-onii)aratively   rare.      in  a  series  of  21.757  cases 


352  SYPHILIS. 

of  syphilis  they  were  observed  in  88.  They  consist  principally  of  visceral 
gummata  and  cirrhoses,  which  result  in  more  or  less  profound  disturbance  of 
function,  give  rise  to  pressui'e  symptoms,  and  beget  various  secondary  changes. 
Of  the  deep-seated  organs  most  frequently  affected  by  severe  tertiary  lesions, 
the  brain  and  its  membranes  rank  first.  Of  the  abdominal  viscera,  the  liver 
is  oftenest  involved,  while  the  kidneys  are  included  with  rarity.  The  syphilitic 
process  may  go  on  to  lardaceous  or  amyloid  degeneration  of  these  viscera. 

Other  tertiary  lesions  are  destruction  of  the  nasal  cartilages  and  bones,  and 
sinking  in  of  the  bridge  of  the  nose,  associated  with  intractable  and  very  offen- 
sive ozsena. 

Serpiginous  ulcers  of  the  skin  and  raucous  surfaces,  arterial  sclerosis, 
inflammations  of  the  cornea,  iris,  and  retina,  periostitis,  and  cariea  or  necrosis 
of  the  bones  of  the  skull  or  of  the  extremities, — all  occur  from  time  to  time. 
Periosteal  thickening  in  the  form  of  nodes  along  the  tibial  crests  is  quite  fre- 
quently noted.  The  tongue  occasionally  becomes  infiltrated,  hypertrophied, 
and  deeply  fissured  upon  the  dorsum,  or  it  is  the  site  of  gummy  growth  and 
ulceration. 

Locomotor  ataxia  is  very  frequently  though  not  always  associated  with  a 
syphilitic  history.  Individual  muscles  may  exhibit  infiltration  of  the  inter- 
stitial connective  tissue  and  fatty  degeneration  of  fibres. 

Symptomatology. — Primary  Period. — Three  weeks  is  the  ordinary  period 
of  incubation  of  a  chancre.  At  the  end  of  this  time  a  more  or  less  typical 
local  lesion  appears,  which  is  almost  immediately  followed  by  swelling  of  the 
nearest  lymphatic  glands. 

Secondary  Period. — At  the  end  of  six  weeks  the  active  secondary  period  is 
announced  by  the  development  of  moderate  fever — 102°  or  104°  F. — head- 
ache, malaise,  lassitude,  and  possibly  pains  in  the  back  and  legs.  A  chill  may 
precede  the  fever.  At  times  these  symptoms  are  so  severe  as  to  lead  one  to 
suspect  the  commencement  of  a  zymotic  disease.  The  temperature  may  rise 
to  105°  F.,  and  run  an  irregular  course  for  a  week  or  two,  but  the  fever  is 
usually  of  little  moment,  the  temperature  remaining  at  101°  or  103°  F. 
There  is  angina  with  diffuse  redness  of  the  fauces  and  hard  palate.  Some- 
times isolated  small  white  spots  are  to  be  seen  in  connection  with  the  hyper- 
aemia.  The  tonsils  may  be  swollen.  A  modified  rash  or  roseola  develops  pro- 
fusely upon  the  buttocks,  trunks,  and  thighs,  and  there  are  frequently  one  or 
two  papules  upon  the  dorsum  of  the  tongue.  Similar  papules  may  appear 
upon  the  scalp.  They  are  small,  hard,  do  not  tend  to  ulcerate,  and  they  are 
pathognomonic.  Other  forms  of  eruption  may  appear,  but  in  general  early 
cutaneous  syphilides  are  characterized  by  symmetrical  distribution,  lack  of 
pain  or  itching,  rounded  outline,  and  of  a  muscle-red  or  "coppery"  hue. 

The  early  eru])tions  are  usually  erythematous  and  papular,  extensively  dis- 
tributed. The  later-appearing  varieties  include  vesicles,  pustules,  tubentles, 
condylomata,  and  squamous  eruptions,  psoriasis,  lichen,  etc.,  which  are  less 
diffuse,  and  which  tend  to  become  grouped  together  in  localized  areas.  A 
roseola  sometimes    has  been  observed    in  the   mouth.     Several    varieties    of 


svMPTOMATOi.oav.  ;jr>:j 

sy]>liili(l<'s  may  he  siiuiiltaiiO(.iisly  pivM-ni.  In  wmhumi  and,  oix^cially,  in 
children  the  i-DseoIa  may  l.e  very  evaiiesct'iit.  It  is  not  tnimd  possible  to 
]>rovent  tlie  a|)pearaiHv  of  the  secondary   rash    In    any   alx.rtivc  treatment. 

At  the  same  time  wiili  the  cruptiun  a  typical  miifuiis  patch  appears  sunie- 
where  within  the  mouth  or  at  its  aiiirles,  on  the  unno,  ton-ne.  or  buccal 
mucous  membrane,  or  on  tli<'  skin.  A  eommnn  site  tbr  it  i-  opposite  the 
second  molar  tooth.  There  may  be  one  or  -eveial  of  the.-e  pat<-hes,  and  thev 
develop  in  succession  at  irreixidar  and  increa>in(;  intervals  until  the  tertiary 
period. 

Other  common  symptoms  of  this  sta-ic  are  larvno;itis.  with  a  re<l,  drv. 
hyperfcmic  mucous  membrane,  iritis,  and  possiblv  retinitis.  There  is  also 
alojiecia,  and  the  finger-nails  sometim(>>  become  brittle.  The  hairs  of  the 
eyelids  and  eyebrows  may   fall   off". 

The  ulcers,  intlannuations,  and   cutaner)us  syphilides   are  characteri/ed   bv 
lack  of  pain  and  discomfort. 

The  symptom-  and  lesions  oj"  the  secondarv  period  niav  last  liir  two  or 
three  or  more  months,  and  l)e  f()Ilow(Kl  by  an  interval  ol"  ^ood  iM-alth.  which 
continues  for  several  months  or  for  many  years  before  anv  tertiarv  lesions 
arise.  In  other  cases  the  secondary  symptoms  oi-  lesions  eontimie  for  two 
years,  or  until  those  of  the  tertiary  period  succeed  them.  In  man\  eases  thev 
last  about  a  year. 

Tt  should  be  observed  that  not  all  eases  present  the  svm|)toms  ai)ove 
described  with  e(pial  distinctness.  In  many  instances  the  entire  secondarv 
stage  is  ntild,  or,  while  certain  of  the  svmptoms  are  |)roniinent  and  -evere, 
others  are    unnoticeable. 

In  a  certain  proportion  of  cases  a  .syphilitic  cachexia  develops  diirinii,  the 
.secondary  period.  It  is  characterized  by  the  followinii:  features:  The  skin  is 
nuiddy  or  sallow,  the  bowels  are  costive,  the  touijue  is  coated  with  a  white  tur, 
the  breath  is  oft'ensive,  and  there  is  more  or  less  aniemia,  with  headache,  palj)i- 
tation,  and  la.ssitude. 

The  o(!Currence  of  tertiary  .symj)toins  and  lesions  is  favonnl  by  lack  ol" 
proper  antisyphilitic  treatment  in  the  secondary  ]ierio<l  :  by  diatheses  aiul 
cache.xi{P,  such  as  scrofula,  tuberculosis,  scurvy,  (>tc.  ;  by  chronic  aleoludism  ; 
and  bv  conditions  of  want  and  luisery  which  lower  the  ucneral  vitality  ami 
resisting;  power  of  the  .sy.stem. 

T<'rtiarv  svmptoms  show  a  j^reat  predisposition  to  relajtsc.  \\  hen  the 
lesions  occasion  pain,  a-  fre<|Ueutlv  is  the  <'a.sc  with  periostit i.-.  the  pain  is 
markediv  wor-e  at  nii:lit.  If  there  are  cerel.'ral  lesions,  the  pain  is  frcfpientlv 
localized  and  confined  to  a  circumscribed  area  on  one  side  of  the  skull,  which 
is  sore  and  painful  to  the  touch. 

The  encephalopathies  ma\-  result  in  pressure  -yniploms,  such  as  paralyses 
or  convulsions,  or  in  mental  apathy  "r  disturbances  of  the  s|Hi*ial  s<'nM's. 

Various  sxinptonis  will    ari<e  in   conneefion  with  visceral    lesions,  but    they 
will    be   dealt     with    nmler    the    several    liea<lin!j;s    of   the   •lis<'ases    of  sepurute 
viscera,    and    do    not    re(|uire   amplification    here. 
Vol..  I.-ii:-, 


354  •  SYPHILIS. 

Course. — No  other  disease  exhibits  greater  variations  in  eourse  and 
variety  of  feature.  In  some  cases  the  course  is  brief  and  the  symptoms  pass 
almost  unnoticed,  while  in  others  one  outbreak  of  symptoms  succeeds  another, 
yielding  to  no  treatment,  and  involving  in  turn  almost  all  the  organs  and  tis- 
sues of  the  body.  In  cases  of  ordinary  severity  there  is  the  greatest  variety 
in  the  clinical  picture  presented.  In  some  cases,  even  after  a  typical  pri- 
mary sore  has  occurred,  the  secondary  symptoms  are  so  mild  that  they  are 
overlooked.  In  other  instances  the  tertiary  symptoms  may  first  disclose  the 
presence  of  the  disease,  and,  very  exceptionally,  some  of  the  tertiary  symptoms 
have  been  observed  in  connection  with,  or  before,  the  ajipearance  of  decided 
secondary  manifestations. 

When  syphilis  occurs  in  old  age  the  healing  pro(«sses  are  retarded,  the 
<'hancre  is  apt  to  ulcerate  extensively,  the  enlargement  of  the  lymphatic  glands 
is  troublesome,  the  secondary  syphilides  are  especially  confluent,  relapses  are 
frequent,  and  the  tertiary  lesions  are  very  prone  to  give  rise  to  grave  nervou* 
symptoms. 

Terminations. — Much  argument  has  been  expended  on  the  questions  of 
the  self-limitation  and  the  cural>ility  of  syphilis.  Gowers,  who  has  especially 
studied  the  later  manifestations  of  syphilis  in  the  nervous  system,  is,  contrary 
to  the  general  belief,  inclined  to  doubt  the  proofs  of  absolute  cure.  Others 
argue  that  the  possibility  of  reinfection  long  after  the  development  of  active 
symptoms  is  in  favor  of  the  positive  cure  of  the  original  disease,  and,  further, 
that  syphilis  is  a  self-limited  disease,  running  its  course  untreated  in  about 
four  years.  Some  syphilographers  even  claim  that  the  lesions  of  the  tertiary 
stage  outlast  the  disease  itself;  that  is,  the  activity  of  the  disease  is  entirely 
expended,  while  the  new  growths  which  it  occasioned  are  more  permanent. 
On  the  other  hand,  treatment  may  remove  all  traces  of  local  lesions,  and 
yet  the  disease  breaks  out  anew.  For  example,  a  syphilitic  woman  has  been 
known  to  give  birth,  in  turn,  first  to  a  stillborn  syphilitic  infant,  secondly, 
while  under  treatn)ent,  to  a  healthy  viable  child,  and  finally  to  herself  relapse 
when  the  treatment  was  withheld  (Gowers). 

The  great  majority  of  cases  terminate  favorably  under  proper  treatment, 
and  death  is  comparatively  rare  from  syphilitic  lesions.  The  most  fatal  forms 
are  the  advanced  cases  of  o-ummata  or  other  lesions  of  the  nervous  svstem, 
abscess  of  \\\q  liver  in  connection  with  bone  lesions,  and  alterations  in  the 
arteries,  resulting  in  the  production  of  aneurism  or  occlusion. 

Diagnosis. — In  many  cases  the  diagnosis  of  syphilis  is  sufficiently  obvious 
from  the  distinctness  of  the  lesions.  In  other  instances,  especially  in  obscure 
cases  of  the  tertiary  ])eriod,  a  very  careful  cross-examination  of  the  patient  fails 
to  elicit  any  history  of  early  infection,  and  a  correct  diagnosis  is  largely  aided 
by  the  res})onse  to  treatment.  Caution  should  be  observed  in  questioning  some 
patients,  esj)ecially  married  women,  as  great  care  should  be  exercised  in  avoid- 
ing interrogations  which  might  occasion  suspicion  or  extensive  family  discord. 
In  such  cases  a  diagnosis  can  often  be  obtained  through  indirect  queries  in  re- 
gard to  the  existence  of  eruptions,  alopecia,  angina,  swollen  glands,  etc. 


LKSIOmS    OF    THE    TFMTIAUY    I'FL'IOD.  \\hr^ 

The  diagnosis  of  an  extra-genital  dianciv  is  lurnicHl  uiK»n  tiic  uciioral  aspect 
of  the  sore,  the  induration  at  its  base,  with  a  teiideney  to  form  a  scab,  espe- 
cially where  a  liairv  surface  retains  the  viscid  secretion,  and  the  cnlaro-cinent  of 
the  nearest  lymphatic  glands,  although  the  indolent  course  of  the  latter  is  not 
as  pronounced  as  it  is  in  genital  syphilis.  In  extra-genital  chancres,  while  the 
induration  is  commonly  distinct,  it  is  frequently  absent  when  the  site  of  the 
oliancre  is  on  the  finger  or  tongue.  Sometimes  the  induration  is  obscured  bv 
csuisties  or  irritation. 

The  early  diagnosis  is  often  rendered  difficult  by  the  syn»ptoms  ])assing  un- 
noticet^l  by  the  patient,  who  stoutly  denies  their  occurrence. 

The  true  syphilitic  chancre  nnist  be  distinguished  from  the  soft  non-infec- 
tious chancre  or  "  chancroid."  The  latter  develops  as  a  i)ustule  which  ulcerates 
in  two  or  three  days,  forming  a  dei)ressed  irregidar  sore  with  undermined 
j>eripherv.  The  base  is  not  indurated,  and  there  is  a  seeretioii  of  pus  from  the 
surface.  The  chancroid  appears  earlier  than  the  true  eh;un  re  :  it  bleeds  more 
easily,  and  is  somewhat  painful  on  ])ressure.  The  ulcer  eaii  be  iiKKulated 
upon  healthy  persons,  and  reinoculated  on  the  same  person,  so  that  several 
such  sores  may  appear  together  and  coalesce.  Finally,  it  is  followed  by  n<> 
secondary  symptoms.  In  these  several  resj>ects  it  differs  from  the  true  syphi- 
litic chancre,  yet  the  two  may  occur  simultaneously  by  a  double  infection  and 
at  the  same  point  of  inoculation.  When  there  is  grave  doubt  a>  to  the  real 
nature  of  the  sore,  the  apj)earance  of  symmetrical,  painless  enlaigemeiit  of 
the  Ivmphatic  glands  in  the  groin  confirn)s  the  diagnosis  of  sy|)hilis. 

A  syphilitic  roseola,  accom])anied  by  rise  of  temperature  and  ]>i-ostration. 
is  sometimes  mistaken  for  measles.  The  presence  of  nnicous  patches,  the- his- 
tory of  inoculation,  and  a  careful  examination  of  the  apju-arance  and  distribu- 
tion of  the  rash,  together  with  the  absence  of  the  catarrhal  symptoms  belong- 
ing to  measles,  will  establish  the  diagnosis  of  syphilis. 

AMien  potassium  iodide  is  prescribed  in  doses  of  a  draehni  in  twenty- 
four  hours  without  producing  iotlism,  the  chances  are  very  strongly  in  favor 
of  the  .syphilitic  character  of  a  lesion,  yet  personal  idiosyncracy  in  regard  t(. 
toleration  of  iodine  occasionally  |)revents  this  test  from  being  absolute. 

When  repeated  abortions  occur  without  other  assignable  cause,  and 
especiallv  if  the  foetuses  are  macerated,  syjihilis  may  be  strongly  -ii<peeted  in 
the  mother  if  not  in  the  father  as  well. 

Sequelae. — The  former  existence  of  .syphilitic  disease  can  olten  l>e  recog- 
nized bv  symmetrical  cic^atriees  on  the  extremities  or  fiiee  oi'  in  the  niontli. 
periosteal  nodes  on  the  tibial  crests,  a  suid<en  no>e,  absent  teeth  and  hair. 
corneal  cicatrices  from  ol<l  ulcers,  irregularities  of  the  pupil  Irom  irili>and 
adhesions,  ])erforations  of  the  hard  or  s(»ft  palate,  <leafn«'ss,  etc. 

Prognosis. — The  prognosis  is  excellent  for  alino-t  all  caM'>i  comiiig 
early  under  treatment.  It  is  made  wor>e  by  ehroiii.-  alcolK.livm,  mihI  is  worse 
if  the  disease  develo|>  vcMy  rajtidly  and  s(  vcrely  at  tlicoii-.t.  wjiicli  is  raivly 
the  case;  and  it  is  worse  the  further  the  <lisease  ha-  advaii.ed  wllJH.iit  ni.diral 
control. 


;3;5(}  SVriUhTS. 

Relation  to  Other  Diseases. — Syphilis  bears  no  dofinitc  relation  to  other 
diseases,  hut  it  is  sometimes  noted  that  syphilitic  lesions  are  kept  somewhat  in 
abeyance  while  other  diseases  are  in  progress.  When  erysi[)elas  occnrs  in  con- 
nection with  a  syphilide,  the  latter  may  l)e  actually  improved  when  the  acnte 
infliunmation  has  subsided. 

Prophylaxis. — Syphilis  is  one  of  the  diseases  which  theoretically  might  be 
com|)letely  eradicated,  but  long  experience  has  taught  that  legislation  can  but 
])artially  control  it.  This  question  is  too  broad  for  discussion  here,  as  it 
involves  considerations  such  as  the  compulsory  examination  of  prostitutes, 
soldiers,  sailors,  and  wet-mn-ses ;  government  license  of  houses  of  ill-fame  or 
their  abolition  ;  and  other  allied  problems. 

Syphilis  is  always  more  powerful  for  transmission  in  its  earlier  develop- 
ment, and  is  generally  believed  to  k>se  its  infectious  quality  completely  in 
the  third  stage,   but  not  until   then. 

Treatment. — The  treatment  of  syphilis  is  conveniently  divided  under  the 
following  headings  : 

J.   Local;   II.   Specific;   TIT.   Tonic;  IV.   Hygienic. 

Sy|)hilis  is  a  ])articularly  satisfactory  disease  to  treat,  because  a  large 
mnjority  of  cases,  even  of  those  already  presenting  extensive  lesions,  respond 
]M(>m])tly  to  the  measures  employed. 

A  certain  ]»roportion  of  cases  never  develop  symptoms  of  sufficient  severity 
to  lead  the  j)atient  to  seek  counsel,  and  time  alone  is  the  healing  agent.  Not 
infrequently  the  general  health  of  syphilitic  subjects  is  very  good,  and  it  may 
be  so  good  as  to  lead  them  to  neglect  obtaining  treatment  for  really  grave 
lesions.      Other  ])atients  are  always  suffering  from  one  ailment  or  another. 

I.  The  Loral  Trcatmeni. — The  local  treatment  of  the  initial  lesion  is  of 
little  avail  if  it  has  gained  decided  headway.  Aseptic  or  antiseptic  applications 
arc  mainly  \aluablc  Ibi'  purjmscs  of  cleanliness,  and  not  for  any  abortive  action. 
If  the  chancre  is  seen  very  early  and  if  it  is  very  small,  it  may  be  thoroughly 
cauterized  with  nitric  acid  or  completely  excised,  but  this  eradication  offers  only 
an  indefinite  hope  of  preventing  the  development  of  secondary  symptoms,  and 
of  late  years  it  has  been  very  generally  abandoned.  If  imperfectiv  done  it 
makes  the  original  soi'c  worse.  It  is  important  to  keej)  the  chancre  clean  and 
free  from  irritation. 

Sonu'  authorities  claim  good  results  from  the  local  a]ij)licati(»n  of  a  mercu- 
rial ointment  to  the  chancre. 

The  hx'al  ti'catment  of  the  mucous  ])atchcs  conijM'ises  cautei'ization  bv 
nitrate  of  mercury  oi-  othei-  caustic,  and  cleanliness,  secured  by  ap))licntion  of 
1  :  100(1  (•orrosive-std)limate  solution.  Condylomata  may  be  washed  with  salt- 
solution  and  then  <lustc(l  with  calomel. 

I^'oi-  the  locnl  treatment  of  the  ozfena,  and  affections  of  skin,  bone,  eve, 
and  ear,  the  reader  must  be  referred  to  the  special  articles  u]>on  the  dis- 
<'ases  of  the  organs   involved   and   to  woi'ks  on  surgerv. 

II.  Specific  Treahiient. — '^Piie  two  drugs,  ])otassium  iodide  and  mercurv  in 
it-   vaiious   pr<'])arations,   are  sj)ecific  agents  against  syphilis,   and   are  j)rac- 


LKsioys  or  rni:  TERTiMiv  pkiuoik  wiu 

tically  the  diily  roincHlios  whirli  (•uiitrol  it.  'riicii-  ii>c  in  >\  phili^  is  tluTrlnrc 
roforred  to  :is"s|KviH(^  treatment,"  and  their  employment  in  combination  is 
often  described  as  "  mixed  treatment."'  Ifemedial  mea>nres  are  capable  ot" 
diminishing  the  intensity  and  of  shortening  the  (hn-ation  of  manv  lesions  ot' 
.syphilis,  and  of  greatly  redneinj^  the  chances  of  the  intlction  of  healthv  p»"ople 
by  th(>  syphilitic. 

Merenry  has  been  (>m])loyefl  for  this  pnrpose  for  nearlv  Ibnr  hnndnnl  vears. 
Its  niixle  of  action  is  nid<no\vn.  bnt  it  is  held  bv  those  who  endorse  the  <icirii- 
tlieory  of  syphilis  that  it  kills  the  bacilins.  It  may,  liowever,  only  render  it 
inert,  or  it  may  act  by  destroying  or  antagonizing  the  lencomaines  tbrmed 
through  the  agency  of  the  germ,  or  by  altering  the  tissues  or  "soil"  in  which 
the  germ  naturally  tiirivcs.  At  present  these  qnestions  nuist  remain  purelv 
speculative  initil  lurther  experimentation  and  oi)servation  thi-ow  new  light 
U})on  this  important  toi)ic. 

Tiiere  are  different  views  in  regard  to  the  methotl  of  administering  the  two 
remedies  in  the  several  stages  of  the  disease.  Some  give  potassium  iodide 
alone;  others  give  it  with  mercury  to  favor  the  activity  of  the  latter.  It  is  the 
generally  accepted  belief  that  the  greatest  value  of  juercury  is  in  the  earlier 
course  of  the  disease,  while  potassium  ioilide  is  more  useful  in  the  latei- ;  but 
there  is  a  groMing  tendency  at  present  to  continue  the  mei-cnrial  treatment  into 
the  final  stage  of  the  disease.  We  have  ceased  to  fear  the  continued  use  ot' 
mercury  since  its  action  and  modes  oi'  administration  have  become  betlei* 
understood. 

Treatment,  while  it  does  not  altogether  prevent  the  aj)pearance  of  se<'ondary 
or  even  tertiary  lesions,  exercises  a  strong  control  over  their  extension.  There 
are  some  syphilographers  of  large  experience,  like  Iliitchinson,  who  maintain 
that  syphilis  can  be  aborted  by  treatment  to  such  a  degree  as  to  altogether  suj)- 
press  the  .secondary  stage  and  hasten  the  disai)pea ranee  of  the  juimary  lesion. 

Mercury  is  of  no  avail  while  the  disease  is  still  localized,  but  it  antagonizes 
such  constitutional  symj)toms  as  may  arise  in  the  early  stages.  Tlw  exact 
nuxle  of  its  action   is  not  known. 

Mercury  may  be  employed  in  a  great  variety  of  preparations,  and  due  ic- 
gard  must  be  paid  to  the  circumstances  and  condition  of  the  |)atient.  as  well 
as  to  the  urgenev  of  the  symptoms.  Greasy  and  mahulorons  external  a|)plica- 
tion.s,  besides  being  disagreeable,  ex|)()S(!  the  patient  to  (letccti(»n.  If.  how<ver, 
the  symptoms  are  severe  or  if  eruptions  appear  ni)on  the  fiice  or  head,  it  is 
necessary  to  obtain  prompt  action  of  the  <lnig,  and  this  is  best  done  by  innm- 
tions  of  one-half  to  one  drachm  of  the  mercurial  ointment  or  of  an  oleatc  or 
albinninatc  of  mercury  or  of  a  1  per  cent.  corrosive-sid)limate  solution,  or  eUe 
by  hypoderndc  injection  of  one  of  the  mon- stdnble  preparalion^  ol  nienniy, 
such   as  the  salicylate,  which   have   recently  become   [M»|.ular  with    many  pra.- 

titioners. 

Svphilides  an;  sometimes,  bnt  not  always,  more  benefited    b\   the  h.eal  than 

by  the  internal  use  of  mercury. 

Kiuniirations  are  also  employed.       K<»r  more  continued  \\-<^  the  pn.tiodid*'  of 


s 


358  SYP  HILLS. 

niercurv  in  doses  of  ono-fifth  of"  a  «j;rain  three  times  daily,  or  the  bichloride  or 
biniodide  in  doses  oi'  one-tbrtieth  to  one-twentieth  of  a  grain  may  be  given, 
j)referably  in  solntion,  either  alone  or  in  combination  with  ten  grains  of  potas- 
sinm  iodide.  Some  clinicians  have  a  decided  preference  for  the  gray  powder, 
hydrargyrum  cum  crcta,  in  doses  of  one  grain,  continued  for  six  months  at  a 
time.  It  is  ot'teu  advisable  to  combine  it  temporarily  with  a  little  opiinn  if 
any  sym|)toms  of  intestinal  irritation  appear. 

As  a  proj)hylactic  measure  against  stomatitis  while  taking  a  prolonge<l 
course  of  mercurial  treatment,  it  is  necessary  to  pay  special  attention  to  cleans- 
ing the  teeth,  and  to  gargle  the  throat  and  rinse  the  mouth  after  each  meal  with 
a  5  per  cent,  solntion  of  chlorate  of  potassium  (Eichhorst).  If  the  month  be- 
comes sore,  a  soothing  gargle  of  nnicilage  or  flaxseed  tea,  with  a  drachm  of 
])otassinm  chlorate  to  the  pint  or  with  listerine  properly  diluted,  must  be 
used.  Irritant  or  i)ot  food  should  be  withheld,  and  smoking  must  be  forbid- 
den.    Laxatives  are  also  indicated. 

Should  any  of  the  characteristic  symptoms  arise — such  as  tenderness  or 
welling  of  the  gums,  foetor  of  the  breath,  slight  salivation,  or  diarrluEa  and 
abdominal  pains — it  is  an  indication  that  the  physiological  limit  of  the  mer- 
cury has  been  passed,  and  the  drug  must  be  promptly  withheld  until  the 
unfavorable  symptoms  subside.  Any  diet  which  is  liable  to  over-stimulate 
the  intestines  and  cause  diarrhoea  should   be  avoided. 

It  is  wrong  to  give  mercury  when  the  diagnosis  is  doubtful,  and  useless  to 
give  it  in  the  first  few  weeks  after  inoculation  ;  but  it  should  certainly  be  pre- 
scribed as  soon  as  the  prodromata  of  the  secondary  period  appear.  It  should 
be  continued  for  at  least  a  year,  observing  the  above  precautions,  and  with 
occasional  brief  intern^issions.  It  is  desirable  to  follow  this  medication  with 
a  year  or  two  longer  of  "  mixed  treatmeut,"  the  duration  of  the  treatment 
being  regulated  somewhat  by  the  intensity  and  variety  of  the  earlier  symp- 
toms. It  is  well  to  combine  some  preparation  of  iron  with  the  mercurial 
treatment  for  its  tonic  effect  and  to  counteract  anaemia.  If  the  symptoms 
become  suddenly  lu'gent  at  any  time,  a  speedy  effect  may  be  obtained  by  the 
internal  use  of  calomel  in  doses  of  one-tenth  of  a  grain  everv  hour  for  a  few 
<  loses. 

The  iodides  of  potassium  and  sodium  are  pre-eminently  valuable  in  the 
third  period  of  syphilis,  and  the  iodide  treatment  must  be  continued  for  at 
least  two  years  in  most  cases,  or,  better,  for  three  years,  to  render  the  patient 
tolerably  secure  from  the  outbreak  of  fresh  manifestations  of  the  disease.  An 
ordinary  dose  for  continued  use  as  a  preventativ<'  of  new  symptoms  is  ten 
grains  thi'ice  daily,  given  in  milk  or  in  the  compound  syrup  of  sarsaparilla, 
which  conceals  the  peculiar  taste  entirely.  The  drug  should  always  l^ 
well  diluted.  WJien  decided  lesions  and  symptoms  demand  it,  the  daily  quan- 
tity of  the  iodide  is  gradually  increased  by  adding  five  grains  of  the  iodide  or 
five  drops  of  a  saturated  aqueous  solution  to  each  dose,  until  a  half-drachm  or 
a  drachm  is  given  thrice  daily.  In  exceptional  cases,  especially  where  pres- 
sure-symptoms are  produced  by  gummata  of  the  imj>ortant  viscera  or  of  the 


TREA  TMF:NT.  359 

x'entral  nervous  .sysUMu,  or  when  any  serious  romplieiitious  supervene,  sueh 
iis  convulsions  or  paralyses,  it  is  of  vital  iuiportauee  t4>  saturate  the  system 
with  the  reniedv  as  ranidlv  as  possible:  and  it  luav  be  necessarv  to  admin- 
ister  half  an  ounce,  or  excej)tioually  au  ounce,  of  the  iodide  in  the  course 
of  twenty-foiu"  hours.  As  a  rule,  syphilitic  patients  show  great  tolerance  of 
the  drug,  ami  in  au  urgent  cas(>  one  is  justitied  in  giving  very  large  doses 
inunediately,  in  order  to  save  life.  When  the  drug  is  pushed  to  its  full  extent 
i-are  should  be  exercised  to  keep  the  bowels  <tpeu  with  llochelle  salts  or  Dther 
.saline. 

Indications  of  iodisni  are  usually  first  observed  in  a  papulai*  or  pustular 
eruption  which  aj)pcars  upon  the  face,  shoidders,  or  other  portions  of  the  body, 
and  which  often  resend)les  acne.  There  nuiy  be  also  gastro-intc-^tinal  irrita- 
tion, coryza,  and  (edema  of  the  eyelids  and  lips.  When  these  symptoms  appear 
the  drug  must  be  i'e<luced  in  quantity,  but  it  nee<l  not  usually  be  entirely  sus- 
pended. 

The  urine  must  be  frecpiently  examined  in  order  to  be  certain  that  excessive 
elimination  of  iodine  is  not  exciting  albuminuria.  When  the  stomach  rebels 
iigainst  large  doses  a  good  deal  may  be  absorbed  by  the  rectum. 

When  iodism  first  appears,  changing  the  preparation  from  pota.ssium  iodide 
to  the  sodium  salt  will  cause  le.«s  irritation  to  be  produced. 

Occasionally  decided  mental  depression  attends  the  use  of  even  moderate 
doses  of  potassium  iodide,  i)ut  this  effect  is  not  i^^rious,  and  it  passes  away 
with  the  temporary  withholding  of  the  drug. 

In  the  tertiary  period  iodides  are  either  given  alone  or  in  cond)ination  with 
mercury,  the  latter  method  being  quite  in  vogue  at  present.  A  conveni<Mit 
fbrmula  for  this  mixed  treatment  is — 

^,.    Hydrarg.  bichlor.,  Jir.  ^  ; 

Potass,  iodi.,  Rr-  v  ; 

Tinct.  cardamoiu,  <;o., 

Tinct.  gentian,  co.,  «<»•  S"*- 


<)i 


M.     Quantity  for  one  dose. 

I^.    Hydrarg.  biniodi.,  ^''- Tiy  J 

Potass,  iodi.,  ^"*-  v'ii ; 

Syrupi  sarsapar.  co., 
Aquse, 
M.     (Quantity  for  one  dose. 


('td.  .^s. 


The  medicine  should  be  well  <lilut(Hl  in  wat«r,  or  half  a  tund)lcrful  of  wat.'r 
shotdd  be  taken  after  each  dose. 

In  a  certain  proportion  of  (.ises  repeate<l  courses  of  treatment,  int(.rrupt«Hl 
<,nce  in  six  or  eight  weeks  fbr  au  interval  of  :,  week  or  ten  days,  sm.re  l>ctU'r 
results  than  contimied  doses,  to  whi.^h  the  system  luromcs  munnl. 

The  specific  treatment  of  syphilis  should  be  continued  u.  the  above  nmn- 
u<;r  for  at  least  a  year  afW  all  symptoms  hav  i,n>ne. 


360  SYPJIILIS. 

111.  and  IV.  Tonk  and  Hygitnu-  Trcainwnt — The  specific  treatment  of 
KVpliilis  is  of  little  avail  witlioiit  tlie  use  of  tonics  and  proper  hygienic  regu- 
lations. The  tonic  treatment  consists  in  the  administration  of  phosphates, 
cinchona,  arsenic,  strvchnine,  or  cod-liver  oil,  and  iron  should  be  given  in  con- 
nection with  one  or  other  of  tiiese  remedies. 

The  Hygienic  Treahnent  includes  the  careful  supervision  of  the  patient's 
daily  habits  of  life.  Abundant  fresh  air,  frequent  bathing,  warm  clothing, 
(hdy-regulated  exercise  and  rest,  and  a  nourishing  diet  are  of  great  importance. 
It  is  almost  useless  to  attempt  the  specific  treatment  of  .syphilis  without  accom- 
panying it  with  an  appropriate  hygienic  regimen.  Under  the  latter  conditions 
a  patient  who  has  been  upon  a  })rotracted  course  of  the  iodide  witiiout  benefit 
will  often  show  very  rapid  improvement. 

Of  course  indulgence  in  sexual  intercourse  should  be  forbidden,  at  least 
until  the  third  .stage  of  the  disease  is  reached,  not  only  on  the  patient's  own 
account,  but  to  prevent  inoculation  of  others,  and  the  use  of  alcohol  should 
be  greatly  i-estricted,  and,  if  possible,  interdicted  entirely.  The  patient  should 
be  rea.ssured  as  to  the  probable  favorable  termination  of  his  symptoms,  and 
made  to  appreciate  the  importance  of  a  strict  compliance  with  the  rules  laid 
down   for  him. 

Special  directions  in  regard  to  diet  should  be  given  in  order  to  keep  diges- 
tion at  its  best.  The  dietary  need  not  be  greatly  restricted,  but  it  should  be 
plain  and  wholesome.  Fr]iits  and  the  coarser  cereals  are  u.seful  on  account  of 
their  laxative  effect,  for  patients  are  much  less  apt  to  suffer  from  iodisni  if  the 
digestion  be  normal  and  the  bowels  freely  opened. 

Summartj  of  Treatment. — As  soon  as  the  secondary  sym})toms  appear  the 
patient  should  be  put  upon  a  daily  mercurial  treatment,  to  be  continued  for  a 
year  and  a  half  The  dose  should  be  moderate,  to  avoid  salivation.  It  must 
be  at  once  discontinued  should  salivation  appear.  On  the  other  hand,  if  any 
new  symptoms  develop  it  may  be  temporarily  increased.  The  iodide  of  potas- 
sium may  be  added  at  the  end  of  the  first  year,  and  it  should  be  continued  for 
eighteen  months  longer.  The  tonic  and  hygienic  treatment  nnist  be  begun 
early,  and  persisted  in  while  any  symptoms  reinain. 

After  two  and  a  half,  or  better,  three,  years  of  such  treatment,  and  if  no 
.symptoms  return  within  six  months  or  a  year  after  its  discontinuance,  the 
patient  may  be  regarded  as  cured,  and  he  may  marry  Avithout  endangering 
either  mother  or  offspring. 


HEREDITARY  SYPHILIS. 

Definition. — Hereditary  or  congenital  syphilis  is  that  variety  of  the  dis- 
ease which  is  transmitted  from  one  or  both  parents  to  their  offspring.  It 
exhibits  great  variety  in  its  manifestations,  but  the  only  essential  difference 
in  symptoms  or  course  from  acquired  syphilis  is  the  absence  of  the  stage  of 
chancre.     It  is  usually  "  conceptional  " — i.  e.  it  is  transmitted  from  either  one 


11  ERE  I)  IT  A  R  Y  SYPHIL  IS.  3(;i 

or  both  parents  at  the  tiiiu-  of  cniuvptioii,  the  virus  liavin*r  attW-ttil  tlio  ovmn 
or  the  spermatozoon.  It  may,  however,  be  traiismittiHl  to  the  embryo  from 
the  bh)od  of  the  motlier  at  any  period  of  phieental  eireiilation,  and  in  this  ciise 
the  disease  is  apt  to  be  less  severe. 

Synonyms. — Erbsyphilis  ((Jer.) ;  Syphilis  hereditaria. 

Etiolog-y. —  The  following;  statements  in  rei:;ard  to  hereditarv  svphilis  have 
been  attested  by  numerous  reportcnl  eases,  and  are  wortliv  of  note. 

When  the  Father  On/i/  is  Si/phi/ltir. — If  aetively  syphilitic — /.  «.  with 
])rimary  or  secondary  lesions — the  father  usually  transmits  the  disease  to  the 
ehild,  but  no  definite  relation  exists  between  the  severity  ttf  the  disease  in 
father  and  ehild. 

This  form  of  infection  is  the  least  injurious  t(»  the  ehild.  The  father  mav 
infect  the  mother  throuiih  the  circulation  of  the  c-hild  //(  atcid.  This  latter 
statement  has  been  denied  by  some  syphilographers  ;  Itiit  whether  the  mother 
.shows  active  syphilitic  symptoms  or  not,  it  is  believed  by  manv  observers  that 
a  .syphilitic  infant  cannot  infect  its  own  mother  after  birth,  even  though  it 
virulently  inoculates  a  healthy  wet-nurse.  This  is  known  as  "Colles's  law;"' 
and  even  if  the  mother  does  not  develop  extensive  lesiitns  herself,  it  indicates 
that  she  has  been  rendered  immune  to  any  external  inoculati<»n  lioni  her  oH- 
snring,  Eichhorst  strenuouslv  denies  the  validitv  of  this  hiw,  and  savs  that 
he  has  seen  mothers  infected  by  their  syphilitic  iidants  after  birth  throuu,h 
abrasions  of  the  nipple,  etc.  Such  a  mother  becomes  antemic,  and  i>  a|)t  to 
Imve  more  or  less  glandular  enlargement  and  periosteal   iuHamniation. 

Manv  more  children  are  inlected  bv  fathers  than  bv  mothers,  because  more 
males  have  syphilis,  andiiot  because  the  disease  is  more  readily  transmitted 
by  males.  If  the  mother  should  have  the  disease,  she  is  »|uite  as  apt  to  trans- 
mit it  as  is  the  father. 

When  the  Mother  Oii/t/  is  Si/j)hi/iti<\ — If  the  mother  be  syphilitic  prior  t«» 
conception,  she  iidects  the  ovide,  or  she  may  infect  the  embryo  at  a  later 
period.  In  such  cases  the  disease  is  often  more  vii-nlcnt  in  the  iidluit  than 
when   inherited   ironi   the  father  alone. 

The  infant  has  the  best  chance  of  escape  when  both  parents  were  healthy 
at  the  date  of  conception,  but  the  mother  subsequently  accpiires  syphilis  a  W'w 
months  before  giving  birth  to  the  child.  Tiider  these  cireums(anc<'s  it  is  rare 
for  the  child  to  be  affected,  and  the  later  the  mother  cdiitract-  the  disease  the 
better  chance  the  child   has  of  escaping. 

It  is  possible  for  syphilis  in  the  mother  to  be  ><>  niodilied  by  treatment  that 
the  chihi  escapes  entirely.  A  child  is  nest  itd'ecte<l  during  labor  by  passing 
over  a  vatrinal  chancre  or  mucoii<  patch,  cither  because  it  is  alreadv  |ir(itectcd 
bv  intra-uterine  inoculalion  or  by  its  uwu  vei  nix  ease<»sa. 

.Abortion  occurs  in  ap|)roximately  une-third  of  all  syphilitic  w<Hiien  (  Tar- 
rot),  and  it  is  especially  prone  to  (k-ciu-  whili-  seeuudary  svinplums  are  actively 
<leveloi)ing  in  the  m<.llier.  It  cniiinmnlv  take-  pla<v  at  the  third  «»r  fourth 
month,  and  the  fietns  is  fre.pK'iil  ly  II'UimI  macraled.  if  iniM-arriagc  (Mcur< 
alter  the  |.ei-iod  of  viability,  the  <liild  is  apt  l<.   l-c   boin  .k  a.j.       This  may  als«. 


362  '  SYPHILIS. 

occur  if  the  mother  were  originally  healthy,  the  child  having  been  infected 
through  the  father.  After  the  birth  of  a  syphilitic  child  the  placenta  is  found 
diseased  bv  proliferation  of  cells  in  the  villi,  extravasations  of  blood,  and  com- 
pression of  the  vessels  by  new  cells  and  connective  tissue  (Fraenkol).  The 
whole  organ  is  enlarged,  and  it  may  contain  gummy  or  calcareous  nodules. 
V^ascular  obliteration  is  chiefly  responsible  for  the  death  of  the  foetus  by  cut- 
ting off  its  supplv  of  nourishment.  The  umbilical  vessels  are  found  to  have 
thickened  walls,  and  there  may  be  thrombosis  of  the  umbilical  vein. 

When  Both  Parents  are  Syphifitic. — It  is  asserted  that  both  parents  may 
have  active  syphilis  and  yet  beget  a  healthy  child.  This  is  certainly  a  rare 
occurrence,  but  it  may  transpire,  even  with  secondary  lesions,  provided  both 
parents  have  been  for  some  time  under  treatment. 

On  the  other  hand,  both  parents  may  have  a  very  mild  type  of  syphilis, 
and  yet  transmit  a  very  severe  form  of  the  disease  to  the  child.  If  the  father 
is  syphilitic,  and  the  mother  first  becomes  so  in  the  later  months  of  pregnancy, 
tiio  hereditary  syphilis  in  the  child  will  probably  be  intensified  (Neumann). 
Both  parents  are  less  liable  to  beget  children  who  are  syphilitic  after  the  dis- 
<'ase  is  a  year  old,  but  Fournier  collected  notes  of  60  ceases  of  hereditary  syph- 
ilis where  the  disease  had  existed  in  one  or  both  parents  for  more  than  six 
years.  He  recently  published  statistics  of  500  syphilitic  families  in  which 
there  were  1127  pregnancies.  Of  these,  600  resulted  in  the  birth  of  healthy 
children,  but  46  per  cent,  ended  in  abortion,  early  foetal  death,  or  syphilitic 
infection.  The  infant  mortality  when  inherited  from  the  father  alone  was  28 
l)er  cent.  ;  from  the  mother  alone,  60  per  cent.  ;  from  both  parents,  68  per 
cent.  Le  Pilenr  {)laces  the  mortality  even  higher,  and  declares  that  not  over 
7  per  cent,  of  the  children  of  syphilitic  mothers  outlive  the  disease. 

Parents  still  capable  of  begetting  syphilitic  children  are  said  to  be  in  a  con- 
Jition  of  "  syphilization." 

Parents  having  tertiary  syphilis  do  not  beget  children  who  are  actively 
syphilitica,  but  they  are  weak  and  atro[>hic.  Among  such  children  are  some- 
times found  cases  of  chorea,  epilepsy,  hydrocephalus,  and  idiocy. 

Curious  anomalies  are  sometimes  observed  among  the  children  of  actively 
syphilitic  parents.  Thus  Hutchinson  has  reported  a  case  of  birth  of  twins, 
one  of  whom   was  syphilitic  and  the  other  not. 

Morbid  Proces.se)i  in  General. — Hereditary  syphilis  may  develop  during 
embryonic  life,  or  it  may  remain  latent  for  a  varying  ])eriod  after  birth,  even 
u|)  to  twenty  years.  In  the  great  majority  of  cases  it  a|)j)ears  before  the  child 
is  three  months  old.  In  the  embryo  and  itifant  it  occasions  cachexia,  dys- 
trophies, malformations,  and  predisposition  to  various  morbid  changes 
(Fournier). 

Considerable  doubt  exists  as  to  whether  these  malconditions  can  be  trans- 
mitted to  the  third  generation  without  fresh  infection. 

Among  the  dystrophies  are  slow  general  growth  and  retarded  puberty  and 
virility,  so  that  the  subject  still  appears  like  a  child  when  eighteen  or  twenty 
years  old,  with   a  pasty  complexion,  scanty  hair,  irregidar  thickenings  of  the 


c 


HEU  EDIT  A  n  Y  S  Y Pill  LIS.  36:{ 

skull,  periosteal  iioiles  on  the  tibiiv  and  olsewlierc,  keratitis,  and  serratetl  ineisor 
teeth. 

Among  the  rnaltorniations  which  are  found  to  aceoujpany  conticnital  syph- 
ilis are  hare-lip,  spina  bifida,   hydroeophalns,  clnb-tbot,  and   vari<.us  hernia\ 

Among  the  morbid  predispositions  there  is  a  tendency  to  a  variety  of  neu- 
rotic affections  and  to  readily  acquired  convidsions. 

Hereditary  syphilis,  although  not  at  all  identical  with  them,  is  often  asso- 
ciated with  scrofula,  rachitis,  croujt,  or  tuberculosis. 

Morbid  Anatomy. — The  morbid  anatomy  of  hereditary  syphilis  does  not 
<litfer  essentially  from  that  of  the  ac(|tiircHl  form.  The  pathology  of  the 
inflammations,   mucous  lesions,   and  gummata  is  identical. 

77/('  mucous  /f.v/o7(,s'  which  are  most  fre(|uentlv  obsci-ve<l  are  hvpcriemia 
and  papillary  infiltration,  labial  fissures^  mucous  pla<[ues  or  patches  (»n  the 
inner  buccal  surface,  and  on  the  gums,  tongue,  n(jse,  and  genitalia,  liarg** 
phagedjcnic  or  gangrenous  ulcers  may  invade  the  |)harvn.\  or  larvnx.  '["hesc 
])atches  may  extend  and  leave  extensive  cicatrices.  Intlammation  may  spread 
<dong  the  Eustachian  tube,  and  involve  the  middle  ear  in  a  purulent  otitis, 
resulting  oftentimes  in  neuroses  and  permanent  deafness.  In  severe  eoryza, 
beginning  with  hypersemia  and  excessive  secretion  from  the  Schneiderian 
membrane,  thick  crusts  form,  with  necrosis  of  tis.sue  beneath  and  ulceration, 
^riie  inflammation  and  erosion  finally  involve  the  bones  of  the  iki-:iI  sejituni, 
producing  a  sinking  in  of  the  nose,  which  becomes  deformed  l"oi-  life. 

The  cutaneous  lesions  are  j)olymorphous  syphilides,  but  chiefly  papidar. 
Thev  are  either  bullous  (pemphigus  neonatorum)  or  erosive  papides  and  |)us- 
tides,  or  psoriasis,  or  simple  roso^ola  of  a  coppery  hue.  There  ar«>  also  ulcci-s 
of  various  sizes,  moist  or  encrusted,  and  condylomata  with  flattened  encrusted 
surfaces  and  a  fcietid  discharge.  The  oidy  characteristic  syphiloderm  of  infan- 
tile or  hereditary  syphilis  is  pemphigus,  which  in  its  specific  form  has  a  pap- 
ular base,  such  as  occurs  in  other  eru])tions  of  the  secondary  stage.  Tlic  blebs 
are  either  trans])arent  or  oftener  are  distended  by  brownish  or  even  bloody 
fluid.  Thev  cover  an  area  of  inflamed  re<l  skin,  and  :u-e  sini-ounde<l  by  a 
faint  areola.      .V  favorite  site  for  them   is  on   the  palms  and  soles. 

The  various  sy|)hilodermata  are  to  be  sought  es|)ecially  upon  the  genitalia 
and  the  ]>erii>hery  (»f  the  anus  and  mouth,  and  on  the  scalp.  The  papules  and 
<'ondylomata  are  a))t  to  occur  in  the  deeper  flexures  of  the  skin  of  the  neck 
and  joints,  where  there  is  more  or  less  irritation  from  opposing  surfaces. 
Within  a  few  weeks  after  birth  a  simple  roseola,  with  irregidar  round  or 
oval  macides,  may  ai)pear,  commencing  on  the  abdomen,  and  later  .>|>reading 
over  the  bod v  and  lind)s.  It  is  dry  at  first,  and  fades  on  jiressurc  ;  lat<'r  it 
acfpiires  a  |)ermancnt  darker,  c».ppery  hue.  It  may  become  moist,  or  scaly 
where  the  skin  is  thick,  and  it  forms  papides  with  eeilidar  inliltrati(»n. 

The  liver  is  permeated  with  nbro-|)iastic  material  an<l  cml)rv<mic  cells.  The 
«-apillaries  are  occluded  or  coiiiprcs.se<I,  and  the  whole  organ  is  large,  hard,  yel- 
low, and  anajmic.  There  is  int<rstitial  sclerosis,  with  cfdlcctions  of  roimd 
Ivmph-cells  resembling!;  microscopic  t^umjnata  (Cornil). 


364  SYPHILIS. 

The  pancreas  niav  undergo  fatty  degeneration.  There  may  be  purulent 
defeneration  of  the  thymus  gland,  but  this  is  not  typical.  The  lymphatic 
glands  Tuay  become  more  or  less  enlarged. 

The  spleen  is  often  enlarged  by  simple  hypersemia  or  there  is  hyi)erplasia. 

In  the  nervous  system  lesions  of  the  meninges  and  blood-vessels  predom- 
inate and  are  very  fatal.  They  may  produce  hemiplegia,  ])aralyses,  convul- 
sions etc.  There  mav  be  cerebral  gumiuata.  These  lesions  occur  at  any  age 
after  the  tirst  few  months. 

There  is  frequentlv  corneal  imflannuation,  with  opacity  or  interstitial  kera- 
titis and  photoi)hobia. 

The  teeth  exhibit  characteristic  changes.  There  arc  vertical  single  notches 
at  the  edges  of  the  upper  middle  incisors.  These  teeth  are  short  and  narrow. 
(See  Fig.  23).     The  notches  belong  to  the  second  dentition,  and  are  said  by 

Fig.  23. 


Notched  Central  Incisor  Teeth  of  Hereditary  Syphilis  (Hutchinson). 


Hutchinson  to  be  pathognomonic,  though  various  other  writers  attach  much 
less  im|)ortance  to  this  condition.  The  notches  are  usually  attributed  to  the 
influence  of  stomatitis  upon  the  young  growing  teeth. 

The  teeth  of  both  the  first  and  second  dentition  are  very  irregular  in  size,, 
development,  and  position,  and  they  decay  easily,  for  the  enamel  is  very  soft. 

Tertiary  Lesmm. — Among  the  gravest  of  the  tertiary  lesions  are  inflamma- 
tions of  the  bones  and  joints  and  gummata.  The  lesions  may  be  congenital 
or  develop  during  early  childhood.  There  may  be  gummy  infiltration  of 
the  phalangeal  and  other  joints.  There  are  enlargement  and  discoloration 
about  the  joints  and  effusion  into  their  cavities. 

The  bones  which  are  very  frequently  involved  are  those  of  the  forearm  and 
leg,  the  humerus  and  femur,  clavicle  and  sternum.  Other  favorite  sites  are 
the  bones  of  the  nose  and  skull,  and  the  cartilages  of  the  larynx  and  trachea 
are  sometimes  atl'ected.  Extensive  cellular  ])roliferation  commences  where  the 
bones  are  actively  growing,  especially  in  the  long  bones  above  mentioned, 
between  the  shaft  and  epiphiseal  end.  The  normal  process  of  ossification  is 
altered  and  retarded.  By  i>ressure  the  new  cells  occasion  degeneration  and 
necrosis.  Osteo-chondritis  and  osteo-myelitis  ensue.  Pus  may  burrow  out- 
ward beneath  the  periosteum.  There  may  be  an  excessive  deposit  of  lime 
salts,  which  encrusts  the  cartilage  and  projects  into  its  substance.  Granulation 
tissue  intervenes  between  this  deposit  and  the  shaft  of  the  bone,  and  the  shaft 
itself  may  be  thickened  by  a  growth  of  new  bone  on  the  outer  surface.  The 
epij)hyses  and  diaj)hyses  of  the  long  bones  may  become  separated,  giving  crep- 
itus, and  spontaneous  fracture  of  the  shaft  has  been  known  to  ensue. 

Periostitis  occurs  over  many  bones,  especially  where  they  have  the  thinnest 


.V  YMPTOMA  TOLOa  V.  :J«)5 

oovering  of  soft   parts,  and   arc  foiisoijiu'iitly  ii>.>r»'   lial)lo  to   injiuN ,  like  tlic 
sternum  and  tibia. 

The  more  cxtcnsivo  lesions  of  tlio  hones  and  Joints  cause  deformities  and 
loss  of  ahility  to  move  the  lind)s.  S('\(>re  hone  thsetise  will  eanse  the  death 
of  the  infant  through  septic  infection  or  exhaustion. 

The  gnmniata  of  infantile  syphilis  are  not  often  developed  at  hirth,  and 
they  may  not  aj>pear  before  the  child  is  eight  or  ten  vears  of  age.  Thcv  an- 
frequently  found  in  the  livei-  in  conneetion  with  an  interstitial  he|)atitis,  wliich 
<'anses  eidargement  of  that  organ,  and  sometimes  ascites.  A  few  gummv 
nodules  may  invade  the  walls  of  the  jiulmonarv  vessels  or  bronchioles  even 
in  the  foetus. 

The  disease  shows  but  two  periods,  the  chancre  of  the  first  stage  of  the 
aequired  affection  being,  of  course  absent  in  the  hereditary  foi-m.  In  conse- 
(juence  of  this  we  do  not  find  the  local  eidargement  of  the  lymphatic  glands, 
although  a  universal  adenopathy  is  often  to  be  discovered  later. 

Tiie  secondary  period  lasts  for  about  a  year  or  a  year  and  a  half,  either  com- 
mencing with  birth  or.  more  frequently,  Mithin  four  or  six  weeks  aftei  birth. 

The  tertiary  period  nuiy,  in  bad  cases,  overlaj)  the  secondary,  and  develop 
very  early  in  the  history  of  the  disease  as  compared  with  acquire<l  syj>hilis. 
The  gurnmata  in  .such  instances  aj)])c-ar  with  the  se<'ondary  eruptions.  In 
other  eases  there  is  an  interinediat<'  period  of  freedom  from  all  symptoms, 
lasting  from  the  termination  of  the  secondary  stage  until  the  second  dentition 
or  ]iul)erty. 

Symptomatology. — A  large  number  of  infants  with  hereditary  syphilis 
appear  healthy  when  born,  and  do  not  develop  any  symptoms  for  several 
weeks.  Even  when  .symptoms  or  lesions  appear,  they  are  not  alway>  recog- 
nized as  l)elonirino:  to  svi)hilitie  disease.  The  chancre  being  absent,  the  ilis- 
ease  commences  its  manifestations  with  the  symptoms  which  correspond  with 
the  se<'ondary  stage  of  the  acquired  form.  There  is  an  crythemato-|)apular 
eruption  or  a  simple  roseola  on  the  buttocks  and  about  the  g<nitalia,  whi<h 
mav  .spread  to  other  regions  of  the  body.  In  a  typical  case  there  is  obstinate 
corvza  with  a  watery  nasal  discharge  and  sun  Hies,  and  roseola;  the  voice  is 
hoar.se,  and  the  crv  is  of  a  peculiarly  harsh  and  irritating  I'nithrc.  This  is  due 
to  the  presence  of  larvngeal  hyju'raMnia  or  to  mucous  patclu-.  When  the 
<'Orvza  is  severe  the  nasal  secretion  becomes  very  thick,  and  drii-s  in  .scabs. 
The  child  will  then  l»e  unable  to  suckle,  beciUise,  th«-  nasal  passages  U-ing 
obstructed,  the  mouth  nmst  be  constantly  employed  in  breathing,  and  it  can- 
not be  closed  long  enough  for  the  child  to  draw  any  milk  from  the  breast. 
Su<-h    infants   may   actually   starv<-   to  <leatli    uid<'s>   li'd    by    a   spoon. 

The  nreas  of  s|)lenie  and  hepatic  dulness  may  be  somewhat  enlarge^!. 

The  skill  is  po(.rl\  nourishe<l.  muddy,  dry,  inelastic,  and  fl:d.bv  ;  the  hair 
i^  thin  an.!  pnlelies  of  alopecia  a|)pear  ;  the  fMiger-nail>  may  iil. crate  ;  .ind  the 
r:i.'i:il  e\pre<-ioii  i<  ein'iously  old  and  wriid<led,  a<  in  mara>mii^.  Tlie  child 
is  dnil  aii<l  li~tle~~.  The  various  svphilidis  of  the  secondary  perio<l  make 
ihiii-  a|>|K-arance.      The  alimentary   canal    i^   irrimble,   and   then'   i-   imp.iireil 


secretion    and    aUsorption.      There    are    oceasional    vomiting    and    diarrhoea. 
More  or  less  bronchial  catarrh  is  commonly  present. 

On  inspection  of  the  cavities  of  the  mouth,  ]>harynx,  and  nose  mucous 
patches  may  be  found. 

Groups  of  lymphatic  glands,  es})ecially  those  about  the  elbow  joint,  may 
be  found  enlarged. 

Later  in  the  tertiary  period  tlie  lesions  of  the  bones  and  joints  appear. 
There  are  inflammation  and  opacity  of  the  cornea,  interstitial  keratitis,  and 
photophobia,  and,  souievviiat  rarely,  iritis.  There  may  be  optic  neuritis  or 
retinitis.  Middle-ear  cratarrh  occurs  in  some  (^ases,  which  may  lead  to  per- 
foration of  the  tym])anum  or  purulent  inflammation  of  the  mastoid  cells. 

Sequelae. — Hereditary  syphilis  often  leaves  permanent  marks  upon  the 
adult  in  the  form  of  notched  teeth,  scanty  hair,  coarse  skin,  and  radiating 
cicatrices  at  the  corners  of  the  mouth  and  elsewhere.  There  may  be  perma- 
nent deformities  produced  by  bone  and  joint  lesions,  impairment  of  vision^ 
deafness,  and   neuroses  or  paralyses. 

Diag-nosis. — The  diagnosis  will  depend  upon  an  accurate  history  of  parental 
syphilis  and  upon  the  appearance  of  the  child.  When  the  infant  is  born  with 
well-d(!veIoped  syphilitic  lesions  of  the  skin,  joints,  bones,  etc.,  the  diagnosis  is 
readily  made ;  but  many  children  present  obscure  or  slight  symptoms  and 
lesions  which  may  be  confounded  with  other  affections.  Others,  again,  show 
no  sym])toms  of  any  kind  until  two  or  three  months  after  birth,  and  such 
children  appear  healthy  and  normal   in  every  respect. 

The  diagnosis  must  often  be  based  on  the  conjunction  of  several  symptoms 
rather  than  upon  any  one.  Such  symptoms  are  the  coryza,  hoarse  voice  and 
cry,  a  prematurely  old  expression,  flabby- skin  and  muscles,  and  the  presence 
of  papules,  pustules,  or  bullae  about  the  mouth,  scalp,  anus  and  genitalia,  or 
on  the  body. 

The  mucous  jiatche.s  may  l)e  confounded,  with  stomatitis.  In  simple 
stomatitis  the  mucous  ])atches  cover  a  larger  surface  and  occur  more  often 
in  the  sulcus  between  gum  and  buccal  mucous  membrane.  The  exudate  is 
serous,  and  vesicles  form  which  are  not  present  in  the  syphilitic  patch. 
In  parasitic  stomatitis  there  are  far  more  inflammatory  action  and  swelling 
than   in  syphilis. 

The  syphilitic  affections  of  the  bones  are  to  be  distinguished  from  rhachitis 
by  the  fact  that  in  the  latter  there  are  symmetrical  enlargement  of  the  epiph- 
yses, slow  closure  of  the  fontanelles,  bending  of  the  shafts  of  long  bones, 
and  a  lack  of  involvement  of  other  structures.  Rhachitic  changes  in  the 
bones  are  rare  in  the  first  half  year,  and  in  sy])hi]is  there  are  usually  cuta- 
neous and  other  sym})toms.  Besides,  there  is  the  history  of  the  case,  which 
will  throw  much   light  upon  it  if  thoroughly  investigated. 

Prog-nosis. — About  one-third  of  all  syphilitic  infants  are  stillborn.  For 
the  remainder  the  prognosis  depends  largely  upon  the  time  of  appearance  of 
the  early  lesions. 

Children   born   with   syphilitic   eruptions  seldom    survive   the    first  year. 


r///-;    TIIREE    J'KRlOJhS.  aG7 

Those  ill  whom  the  disease  develops  shortly  atter  birtii  may  live  for  a  few 
years  with  enl"eeble<l  constitutions  and  then  the,  or  they  may  live  to  become 
adults.  About  one-fourth  of  the  children  born  syphilitic  die  within  the  first 
half-vear.  The  majority  of  infants  in  whom  the  secondary  lesions  are  well 
developed  do  not  outlive  the  secondary  period. 

In  general,  the  later  the  symptoms  develop  the  better  the  chance  of  ulti- 
mate recovery.  If  no  symptoms  develop  within  eight  or  nine  months  after 
birth,  the  child  may  escape  the  second  stage  and  jkiss  on  to  the  third,  or  it 
mav  escape  serious  lesions  altogether. 

If,  on  the  other  hand,  gummata,  periosteal  nodes,  or  other  tertiary  symp- 
toms appear  within  the  fir-st  year,  the  jirognosis  for  nltimat(^  recovery  is 
extremely  bad. 

Treatment, — The  treatment  of  hereditary  syphilis  should  be  commenced 
at  once  through  the  mother  by  giving  her  mercury  and  iodide  of  potassium, 
and  continued  with  the  child  after  birth.  The  transmission  of  syphilis  is 
wonderfully  controlled  by  the  prolonged  treatment  of  the  |)arents,  so  that  the 
mortality  may  be  reduced  from  over  60  per  cent,  to  2  or  3  per  cent.  No  syph- 
ilitic person  should  marry  or  attempt  to  beget  children  within  from  three  to 
four  years  after  primary  inoculation,  and  not  even  within  this  time  unle&s  he 
has  been  under  continuous  observation  and  treatment,  although  the  great 
majority  of  sy})hilitic  parents  do  not  transmit  the  disease  after  the  secondary 
stage  is  over.  After  the  lapse  of  three  yeai-s,  and  if  no  lesions  have  ai)iieared 
within  the  previous  six  months,  it  is  regarded  as  safe  for  a  man  to  marry 
without  endangering  either  mother  or  offspring, 

A  syphilitic  child  must  on  no  account  be  allowed  to  nurse  from  a  healthy 
woman,  as  the  latter  is  certain  to  become  infected  through  a  fissured  nipple 
or  in  one  of  the  numerous  methods   of  extra-genital  contamination. 

The  treatment  of  the  infant  is  governed  by  the  same  princij)les  as  those  of 
the  treatment  of  the  adult.  Mercury  may  be  given  internally  in  (he  form  of 
hydrargyrum  cum  creta  or  as  the  biniodide  or  bichl!)ride,  the  former  being 
preferred  by  many.  V  method  early  recommended  by  Brodie  consists  in 
spreading  a  little  mercurial  ointment,  in  the  strength  of  a  drachm  to  the 
oimce  of  emollient,  nj)on  a  flannel  bandage  which  the  child  wears  over  the 
abdomen;  or  an  ointment  of  one  part  of  red  precijntate  of  mercury  to  lOO 
].arts  of  lanolin  may  be  used.  In  this  manner  enough  of  the  <lrug  is  readily 
al)sorbed  through  the  delicate  skin  of  the  infant. 

Mercury  given  by  the  month  to  young  iiiiants  sometimes  produces  inlcsliual 
colic,  irritation,  and  purging.  In  such  cases  inunctions  are  j.referable.  On  ihe 
other  hand,  if  then-  are  cutaneous  eruptions  or  il'  the  >kiii  Ih  I..(.  tender,  the 
immctions  are  not  desiral)le,  and  ..n.'  of  the  milder  preparations  ol'  men-my 
must  be  selected  fi.r  int.rnal  w-v.  Sli..uld  any  indication  of  stomatitis  appear, 
the  child's  mouth  slionM  be  cleanM-<I  :i(ter  ea.'li  run-ing  by  a  rag  dipped  in  a 
2  jter  cent,  solution  of  chlorate  nl"  potassium. 

When  the  svphilodertiiata  are  extensive  and  refra<-tory,  i)aths  of  corrosive 
sublimate  are  sometimes  useliil.  pi.-vidd  thee  1..    i,..  abraded  surface  to  admit 


368 


SYPHILIS. 


of  too  rapid  absorption.  For  .such  bath.s  Wiederhofer  advises  the  use  of  two 
or  three  grains  of  corrosive  sublimate,  with  fifteen  grains  of  ammonium  chlo- 
ride to  the  half  ])int  of  distilled  water,  to  be  added  to  the  child's  bath-tub  full 
of  warm  water.  Oidy  a  wooden  or  earthen  tub  should  be  employed.  Of 
oour.se  care  must  i)e  taken  to  protect  the  mouth  and  eyes  while  the  child  is 
beini;  bathed. 

As  soon  as  any  evidence  of  tertiary  disease  presents,  the  iodide  of  ])otassiiun 
must  be  added  to  the  mercury  in  doses  of  one-half  to  two  grains  three  times 
a  dav  ;  and  this  mixed  treatment  should  be  continued  even  longer  than  in 
the  adult  before  the  child  is  .secure  from  further  outbreaks  of  the  disease.  It 
juay  seem  advisable  to  discontinue  it  from  time  to  time  for  a  few  week.s,  but 
its  administration  should  be  kept  up  at  intervals  until  puberty.  The  syrup 
of  Gibert  is  a  serviceable  combination  for  children.  It  is  modified  in  various 
ways,  but  in  the  following  formula  it  is  well  borne  : 

II.    Hydrarg,  biniodi.,  gr.  .ss  ; 

Potassii  iodi.,  3ij  ; 

Syrupi  zingiberis  vel  glycyrrhizse, 
M.    Aqute  destil.,  da.  t'sij, 

Sig.    Dose  gtt.  v-x  in  water  for  an  infant  of  six  months. 

It  is  to  be  remembered  that  a  certain  amount  of  potassiiun  iodide  can  pass 
into  the  nursing  infant  from  its  mother's  uiilk  when  she  is  taking  the  drug  in 
considerable  quantity. 

Syphilitic  infants  should  be  bathed  often  and  have  their  diapers  frequently 
changed  to  avoid  irritation  of  the  skin.  If  the  cutaneous  eruptions  are  moist, 
they  should  be  treated  with  mild  astringents  or  with  antiseptic  dusting  pow- 
ders, and  be  j)rotected  from  the  air  and  from  abrasion  by  absorbent  cotton. 
Mucous  ])atches  will  sometimes  require  cauterization,  and  great  care  should  be 
taken  to  keep  their  surfaces  clean  and  to  prevent  their  virulent  .secretions  from 
infecting  others. 

Syphilitic  children  are  feeble  and  do  not  thrive  upon  the  bottle,  .so  that,  if 
the  mother  cannot  mirse  her  own  infant,  a  syjihilitic  wet-nurse  will  be  better 
for  if. 

Infected  infiuits  should  be  very  carefully  isolated  from  healthy  (children, 
who  might  readily  become  infected  by  caressing  them  or  by  using  the  .same 
nursing-bottle,  spoons,  or  toys  wliich  have  been  in  the  mouth. 

The  tonic  treatment  should  be  carried  out  as  in  the  case  of  adults.  The 
saecharated  carbonate  of  iron  in  half-grain  doses  is  well  borne  by  infants,  and 
cod-liver  oil  mav  be  added. 


LEPROSY. 

By  WILLIAM  PEPPER. 


Definition. — Leprosy  is  a  chronic,  infectious,  and  contagious  disease,  cha- 
racterized anatomically  by  tubercular  nodules  of  the  skin  and  mucous  mem- 
branes and  changes  in  the  nerves,  and  clinically  by  various  troplio-neurotic 
manifestations  with  mutilations.  . 

Nomenclature. — The  disease  is  also  called  lepra,  and  was  formerly  known 
as  elephantiasis  Groecorum. 

Historical  and  Geographical. — The  frequent  references  to  leprosy  in  the 
Bible  give  a  peculiar  historical  interest  to  this  disease,  though  doubtless  a 
variety  of  other  aifections  were  confounded  with  it.  It  was  known  from  the 
earliest  times  in  India,  Egypt,  Palestine,  and  Arabia,  and  also,  though  the 
records  are  less  satisfactory,  in  China.  The  first  appearance  in  Europe  was 
about  a  century  before  the  Christian  era,  when  Greek  writers  first  mention  its 
occurrence.  It  invaded  Italy  a  few  centuries  later,  and  Galen  and  Aretteus 
gave  excellent  accounts  of  its  characters.  During  the  Middle  Ages  it  advanced 
throughout  Europe  along  the  lines  of  invasion  of  the  Roman  armies,  and 
assumed  the  characters  of  an  universal  scourge.  As  a  result  of  rigid  enforce- 
ment of  isolation  the  disease  declined  during  the  thirteenth  and  fourteenth 
centuries,  and  at  the  end  of  the  latter  had  disappeared  from  England  and  the 
greater  part  of  continental  Europe. 

At  the  present  time  the  principal  centres  of  leprosy  arc  India,  China,  and 
the  Sandwich  Islands,  the  last  being  of  particular  interest  from  the  fact  that 
the  disease  took  root  in  that  locality  within  the  last  fifty  or  sixty  years.  In 
E^nrope,  Norway,  and  the  Baltic  provinces  of  Russia  are  its  important  foci. 
In  our  own  hemisphere  leprosy  prevails  extensively  in  Mexico,  jiarts  of  Cen- 
tral and  South  America,  certain  of  the  West  Indian  islands,  and  In  r.  less  extent 
in  some  of  the  Gulf  States  of  this  country.  The  last  is  true  i-speeially  of 
Louisiana,  and  in  1891  Blanc  estimated  that  there  were  in  New  Orleans  alone 
fidly  75  cases.  Parts  of  the  province  of  New  P>runswick  are  also  aflectcHl. 
On  the  Pacific  coast  the  disease  is  frequently  seen  aniong  the  Chinese. 

Etiolog-y. — T^eprosy  is  jK-culiarly  a  disease  of  young  ju-rsoiis,  the  great 
majority  of  cases  occurring  from  the  fifteenth  to  the  thirfiefh  ynir.  It  is 
slightly   more  common   among   men.     Social   conditi»»n    |»]:iys  a   i»:ut    in    liic 

etiology  in  so  far  as  squalor  and   overcrowding  expose  to  contagi Iml   all 

classes  of  society  are  susceptible.      Heredity  certaiidy   has  some  inlluence.  as 
several   well-authenticated  congenital  ca.ses  deliniti-ly  i)n.ve.     'i'hr  theory  of 
Vo...  i.-:!i  ■•|»i« 


370  LEPROSY. 

Galen,  lately  advocated  by  Hutchinson,  that  a  diet  of  decayed  fish  leads  to 
the  disease,  is  not  substantiated  by  recent  experience. 

The  specific  cause  is  the  bacillus  leprce,  discovered  by  Hansen  in  1874. 
This  organism  resembles  very  closely  the  tubercle  bacillus,  but  may  be  dis- 
tinguished by  its  staining  properties,  its  shape,  growth,  and  distribution.  It 
occurs  abundantly  in  the  leprous  tubercles,  and  has  been  found  in  the  blood. 
It  has  been  successfully  cultivated,  but  inoculation  of  animals  has  failed  to 
produce  the  disease.  It  has,  however,  been  established  that  inoculation  of 
man  with  parts  of  the  growths  will  cause  the  disease. 

The  contagiousness  of  leprosy  cannot  be  doubted,  though  this  always  re- 
quires direct  inoculation,  as  in  the  case  of  syphilis.  Sexual  congress  has  been 
indicated  as  the  method  of  transmission  in  the  majority  of  cases  (Morrow). 
Instances  of  inoculation  through   vaccination  are  also  recorded. 

Morbid  Anatomy. — The  bacillus  finds  .two  favorite  seats — the  skin  and 
the  nerves.  In  the  former  it  gives  rise  to  the  characteristic  leprous  tuber- 
cles, in  every  respect  similar  to  the  other  granulomata.  Microscopically, 
these  tubercles  contain  lymphoid,  epithelioid,  and  giant  cells,  and  numerous 
bacilli  between  or  within  the  cells.  Eventually  these  tubercles  soften  and  dis- 
charge thick  puriform  material,  or  in  rare  cases  more  or  less  complete  organi- 
zation occurs  and  limits  the  further  progress  of  the  disease.  In  the  nerves 
extensive  neuritis  marks  the  invasion  of  the  bacilli.  In  the  late  stages  of 
the  disease  leprous  new  growths  may  be  found  in  the  internal  organs,  espe- 
cially the  spleen  and  liver. 

Clinical  History. — Two  distinct  types  are  recognized  :  the  tubercular  and 
the  anaesthetic  or  nerve  leprosy,  and  in  some  cases  a  combination  of  the  two 
occurs. 

Tubercular  Leprosy. — The  period  of  incubation  is  indefinite,  some 
cases  having  followed  infection  by  a  few  months,  others  by  as  much  as  twenty 
years.  A  prodromal  stage  of  excessive  sweating,  mild,  irregular  fever,  and 
lassitude  has  been  described,  but  is  rarely  prominent.  The  onset  of  the  dis- 
ease is  marked  by  the  appearance  of  erythematous  patches,  slightly  elevated 
and  hyperaesthetic.  These,  after  a  time,  disappear,  but  return  with  greater 
distinctness,  and  may  then  persist  for  a  long  time.  The  color  of  the  patches 
may  be  a  livid  red,  or  there  may  be  only  a  diffuse  mottling.  In  all  cases, 
when  persistent,  they  become  darker  from  deposition  of  pigment. 

The  tubercles  occur  in  the  skin  and  mucous  membranes.  They  are  partic- 
ularly common  about  the  face,  to  which  they  give  the  heavy  features  desig- 
nated by  the  name  leontiasis.  Other  localities  are  the  ears,  extremities,  mam- 
mary glands,  and  scrotum,  but  all  parts,  excepting  the  seal}),  may  be  involved. 
The  palms  and  soles,  however,  are  rarely  involved.  Of  mucous  surfaces  the 
mouth,  throat,  larynx,  and  Conjurictivse  are  most  frequently  affected.  The 
nodules  vary  in  size  from  a  pea  to  a  large  nut,  or  they  may  run  together,  pro- 
ducing extensive  new  growths.  The  skin  over  the  tubercle  is  tense  and  glis- 
tening, especially  at  certain  times  when  the  redness,  heat,  and  tenderness  indi- 
cate inflammatory  reaction.     The  hairs  of  the  affected  areas  drop  out,  and  in 


DIAGNOSIS.  371 

leprous  countries  disappearance  of  the  eyebrows  is  regarded  a  significant  syni])- 
toni.  Subsequently  tlie  tubercles  soften  and  ulcerate,  discharging  tiiick  yel- 
lowish or  brownish  puriform  matter,  which  forms  thick  crusts  and  contributes 
to  the  repulsive  api)earance  of  the  terminal  stages.  The  ulceration  may  extend 
deeply,  even  involving  the  bone.  This  is  often  seen  in  the  nose,  where  the  sep- 
tum becomes  destroyed,  with  a  falling  in  of  the  bridge  of  the  nose.  In  the 
eye  the  tuberculous  and  ulcerating  processes  cause  extensive  destruction,  until 
the  globe  becomes  a  shapeless  mass.  la  certain  cases,  on  the  other  hand, 
ulceration  does  not  occur,  but  by  organization  of  connective  tissue  destruction 
is  checked,  and  possibly  the  whole  progress  of  the  disease  is  arrested. 

Anaesthetic  or  Nerve  Leprosy. — In  this  form  the  characteristic  symp- 
toms are  the  spots,  the  anaesthesia,  bullas,  trophic  alterations,  and  mutilation. 
No  definite  order  of  occurrence  can  be  assigned  to  the  different  symptoms. 

The  spots  appear  insidiously  or  sometimes  acutely  with  fever.  They  affect 
particularly  the  back,  buttocks,  knees,  arms,  and  face,  and  vary  in  size  from 
that  of  a  small  coin  to  extensive  areas.  At  first  they  are  often  erythematous, 
slightly  elevated,  and  hyperaesthetic ;  later  they  become  pigmented  or  pigment- 
less.  Usually  the  centre  is  light-colored,  the  periphery  dark,  but  the  whole 
area  may  be  white. 

The  characteristic  feature  of  the  spots  is  the  altered  sensibility.  At  first 
hypersesthetic,  they  soon  become  anaesthetic,  and  retain  this  as  a  pathognomo- 
nic feature.  In  addition  to  anaesthesia,  absolute  suppression  of  sweat  from 
the  surface  of  the  spots  has  been  pointed  out  by  Manson  as  a  symptom  of 
great  significance. 

The  bullae  of  nerve  leprosy  occur  at  any  stage  of  the  case,  and  may  con- 
tinue to  appear  for  a  long  period.  They  come  out  suddenly,  last  a  few  hours, 
and  then  break,  leaving  a  red  spot,  which  may  persist  as  a  chronic  ulcer  or 
heal  kindly.  In  size  they  vary  from  that  of  a  nut  to  a  hen's  egg,  and  are 
filled  with  a  vellowish-green  liquid.  The  bullae  occur  in  any  part  of  the  body 
excepting  the  scalp  ;  they  are  frequent  on  the  palms  and  soles. 

As  the  process  of  neuritis  advances  there  is  widespread  hyperaesthesia,  then 
anesthesia  and  pains  radiating  along  the  nerves.  When  large  superficial 
trunks  are  involved,  these  may  be  felt  as  thickened  cords  under  the  surface. 
Later  on,  atrophy  of  muscles,  partial  palsies,  and  various  trt»phic  disttn-bances 
occur.  In  the  hands  may  be  seen  the  claw  hand,  which  also  occurs  in  other 
forms  of  neuritis ;  and  the  phalanges,  as  also  those  of  the  foot,  may  infiame, 
.swell,  and  be  removed  bv  ulceration.  In  the  foot  a  perforating  ulcer  of  the 
sole  is  quite  common. 

Diagnosis. — Tubercular  lci)r<)sy  must  Ik-  distinguished  from  tubercular 
syphilis.  The  distinction  is  easily  made;  by  the  altered  sensation,  by  the 
history,  and  by  the  distribution  of  the  lesions.  Kalindcra  advocates  the 
application  of  a  blister  and  the  examination  of  the  scrum  for  bacilli.  Nerve 
leprosy  is  distinguished  from  vitiligo  and  similar  alVections  by  the  altered  sen- 
sation, and  from  syringomyelia,  or  Morvan's  disease,  by  carefid  examination 
of  sensation,  by  the  partial  palsies,  and  by  the  distinct  spots. 


372 


LEPROSY. 


Prognosis. — The  prognosis  is  always  bad,  but,  as  there  are  at  least  155 
cures  recorded  in  the  literature  of  this  disease,  the  outlook  is  not  hopeless. 
The  tubercular  cases  usually  live  from  eight  to  ten  years,  the  anaesthetic 
fifteen  to  twenty  years.  Acute  cases  witb  rapid  death  have  been  described 
by  Leloir.  The  course  of  the  disease  may  sometimes  be  arrested  or  partial 
restoration  may  occur,  but  this  is  rare. 

The  causes  of  death  are  mainly  exhaustion,  colliquative  diarrhoea,  obstruc- 
tion to  the  air-passages,  and  inspiration  pneumonia. 

Treatment. — Prophylaxis  is  of  the  greatest  importance.  The  good  effects 
of  isolation  and  hygiene  were  seen  conclusively  in  the  subsidence  of  the  disease 
in  Eiu'ope  during  the  Middle  Ages. 

Of  the  many  remedies  successively  praised  and  condemned,  iodide  of  potas- 
sium, arsenic,  chaulmoogra,  and  gurjun  oil  seem  most  worthy  of  trial.  Dan- 
ielssen  after  forty  years'  experience  regarded  the  iodide  as  of  distinct  service. 
It  should  be  pushed  as  freely  as  is  possible  without  producing  iodism.  Chaul- 
moogra oil  in  doses  of  2  drachms  and  gurjun  oil  in  10-minim  doses  may  be 
of  use.  The  latter  has  received  special  attention  of  late.  It  may  be  used  by 
inunction  when  the  stomach  is  sensitive.  Palliative  and  supporting  measures 
will  be  needed  at  the  end. 


DIPHTHERIA. 

By  \V.  oilman   THOMPSON. 


Definition.— DiPHTHEPaA  is  an  acute,  infectious,  and  inoculahle  disease, 
oeeurring  sporadically  and  epidemically.  It  is  characterized  anatomically  by 
a  croupous  inflammation  of  the  mucous  membrane  and  abraded  surfaces. 
This  atlects  chiefly  the  pharynx  and  upper  air-passages,  and  has  a  marked 
tendency  to  spread  to  adjacent  parts.  It  is  attended  with  eidargement  of  the 
associated  lymphatic  glands.  Clinicallv  the  disease  is  marked  bv  irre<>-ular 
fever,  great  debility,  and  frequent  albuminuria;  by  a  tendency  to  death  from 
toxsemia,  from  membranous  croup,  or  from  heart-failure;  by  slow,  uncertain 
convalescence  and  by  peculiar  paralytic  sequelae. 

Synoxyms, — Diphtheritis  ;  Cynanche  contagiosa;  Angina  maligna;  Diph- 
therite  (Fr.) ;  Diphtherie  (Ger.).' 

Etiolog-y. — The  Bac'iUm. — Diphtheria  is  undoubtedly  a  germ  disease, 
caused  by  the  activity  of  the  bacillus.  There  has  been  much  disjmte  as  to  the 
identity  of  the  bacillus,  but  the  clinical  history  of  the  disease  and  all  that  is 
known  in  regard  to  its  propagation  afford  conclusive  proof  of  its  bacillarv 
origin.  A  variety  of  microbes  are  found  in  the  mouth  and  throat  in  connec- 
tion with  diphtheria,  such  as  staphylococci  and  streptococci,  which  render  dif- 
ficult the  isolation  of  a  specific  diphtheritic  germ.  Harmless  germs  may  even 
accumulate  in  the  lymph-vessels  leading  from  the  inflamed  surface.  It  is  an 
important  question,  especially  in  regard  to  any  theoiy  of  treatment,  whether 
diphtheria  is  a-  general  disease  with  a  local  lesion  or  whether  it  is  ])rimarily  a 
local  disease.  In  other  words,  is  there  a  y-eneral  svstemic  infection  which  mav 
give  rise  to  constitutional  symptoms  prior  to  the  appearance  of  any  local  lcsi(»n 
produced  by  action  of  bacteria,  or  are  the  constitutional  symptoms,  lever, 
albuminuria,  paralyses,  etc.,  caused  by  absorjition  of  ])tomaVues  generated  by 
the  agencv  of  the  bacteria  ? 

The  majority  of  authors  are  still  agreed  in  calling  dijihtheria  a  general  or 
constitutional  disease  which  develo])s  a  local  lesion  at  somt^  period  of  its  course, 
though  many  are  inclined  to  advance  the  opinion  thai  in  exceptional  cases  the 
local  lesion  may  first  appear.  Further  researches  in  icgaid  ti>  ihe  bacterial 
origin  and  mode  of  infeeliou  l>v  the  disease  niav  alter  llieir  views. 

The  ba fill II. H  (lijiJif/irri(r  was  discovered  by  Klebs  in  ISS.'^and  by  LiWlIei- 
of  Greifswald  in  1.S84.  It  is  found  in  the  exudate  or  false  membrane  on 
the  surface  of  the  nnicons  menil)rane,  and  is  often  coughed  ont  with  shred.s 
of  pseudo-inenibrane.  The  causative  relation  of  this  germ  to  diphtheria  has 
been  disputed  l)V  some  bacteriologists,  bnt  there  is  accumulaling  e\ii|eiice  iu 
favor  of  its   being  the  originator  ol"  the   disease.      I'^-um    the    fact    that    both 

;i7a 


374  DIPHTHERIA. 

observers  deserve  credit  for  the  discovery  of  the  germ  it  is  often  called  the 
"  Klebs-Loffler  bacillus."  Among  those  who  have  confirmed  the  observa- 
tions and  exjieriments  of  Klebs  and  Loffler  are  Babes,  Ortmann,  V.  Hoff- 
mann, Welch,  Abbott,  and  other  experienced  observers. 

Tiie  Klebs-Loffler  bacillus  has  been  passed  through  a  series  of  twenty-five 
rabbits  by  inoculation  of  the  false  membrane,  and  still  retained  its  virulence. 
The  bacilli  are  more  numerous  and  appear  better  nourished  in  the  pseudo- 
membrane  than  in  prepared  culture  media.  The  diphtheria  bacillus  is  a  little 
shorter  than  the  tubercle  bacillus,  but  is  much  broader  and  has  thickened  or 
clubbed  extremities.  It  is  sometimes  curved,  sometimes  spindle-shaped.  It 
is  2.5-3/i  long  and  non-motile.  It  is  capable  of  deep  staining,  and  then 
presents  a  segmented  granular  appearance.  The  bacilli  often  occur  in  groups. 
On  the  outer  surface  of  the  false  membrane  several  varieties  of  bacilli,  includ- 
ing the  Klebs-Loffler  germ,  are  found.  Immediately  below  is  a  layer  contain- 
ing many  cells  and  but  little  fibrin,  and  here,  again,  the  bacilli  in  groups  are 
apparent.  Finally,  in  the  deepest  fibrin  layer  which  rests  upon  the  mucous 
membrane  no  Klebs-Loffler  bacilli  are  present  (Welch,  Abbott).  The  bacillus 
diphtherise  grows  readily  on  a  variety  of  culture  media.  It  is  killed  at  58°  C. 
in  ten  minutes  (Welch,  Abbott). 

This  bacillus,  inoculated  in  the  lower  animals,  produces  symptoms  resem- 
bling diphtheria,  with  pseudo-membrane,  underlying  necrosis,  paralyses,  and 
albuminuria.  In  man  it  comes  in  contact  with  the  faucial  or  other  raucous  sur- 
face or  the  abraded  skin,  and  propagates  there,  but  it  does  not  penetrate  deeply 
into  the  mucous  membrane,  nor  is  it  taken  up  by  the  blood-vessels  or  lymph- 
atics. The  bacilli  therefore  do  not  invade  the  entire  bodv,  but  remain  at  the 
site  of  the  local  lesion,  imbedded  in  the  pseudo-membrane. 

As  a  result  of  experimental  inoculation  of  the  Klebs-Loffler  bacilli  in 
animals  typical  microscopic  changes  occur  in  various  organs,  notably  the 
liver  and  kidneys.  In  the  liver  Babes  observed  swelling,  degeneration,  and 
also  ])roliferation  of  the  hepatic  cells.  Leucocytes  accumulate  with  frag- 
mented nuclei.  The  capillary  endothelial  cells  are  swollen,  and  the  vessels 
themselves  contain  hyaline  and  yellowish  granular  matter.  Similar  changes 
occur  in  the  renal  ej)ithelium  and  blood-vessels.  These  results  have  recently 
been  substantially  confirmed  by  Welch  and  others.  At  the  site  of  inoculation 
a  gray  pseudo-membrane  ajipears  over  necrotic  tissue  with  extreme  fragmenta- 
tion of  nuclei.  This  is  surrounded  by  an  area  of  hypersemia  and  congestion 
with  ecchymoses.  The  neighboring,  and  even  the  distant  lymph-glands  are 
swolUsn  and  hsemorrhagic.  The  various  serous  cavities  contain  increased 
exudation. 

Oertel  lias  shown  that  these  visceral  and  local  changes  accompany  human 
diphtheria  ;  and  it  is  of  the  greatest  interest  and  value  to  know  that  they  may 
be  experimentally  produced  by  pure  cultures  of  the  Klebs-Loffler  bacillus. 

The  Klebs-Loffler  bacilli  produce  one  or  more  ptomaines  or  toxines,  which 
are  absorbed  by  the  lymphatic  and  blood-vessels  and  give  rise  to  the  constitu- 
tional and  toxic  symptoms.     The  toxines  can  be  generated  by  cultivation  of 


ETIOLOUY.  '?>17^ 

the  germs  in  artificial  media,  and  tlu'v  have  been   nreutly  isolated  ami  iivcd 
from  bacilli  by  Roux,  Brieger,  Fraenkel,  and  others. 

The  Ptomaine. — The  princij>al  ptomaine  when  s\valk>wed,  like  many  other 
poisons,  produces  but  little  eU'ect,  but  when  inoculated  it  causes  unknown 
chemical  alterations  in  the  tissues  of  the  bodv  ;  and  it  is  suQ-o-csted  that  a  certain 
degree  of  immunity  which  follows  an  attack  of  diphtheria  is  due  to  this  cause 
(Fraenkel,  Behring).  It  is  destroyed  at  a  tem])eratm-e  of  about  140°  F.  It 
is  soluble  in  water,  but  is  precipitated  by  alcolu)!.  It  resembles  proteids  in 
composition.  There  is  reason  to  believe  that  the  bacilli  themselves  are  really 
innocuous  apart  from  their  production  of  the  specific  ptomaines.  One 
ptomaine  has  been  isolated  which,  if  injected  into  animals,  causes  increased 
secretion  from  the  mucous  membrane  of  the  eyes,  nose,  and  mouth,  together 
with  chill  and  fever.  This  is  followed  by  convulsions,  involuntary  evacua- 
tions, paralysis,  dyspnoea,  and  death. 

Immunity. — By  recent  experiments  with  inoculation  of  attenuated  cultures 
of  diphtheritic  virus  Behring,  Kitasato,  and  Fraenkel  have  succeeded  in  ren- 
dering certain  animals  immune  to  di})htheria.  With  guinea-pigs  and  rabbits 
Behring  has  been  able  to  regulate  the  dosage  with  almost  mathematical  accu- 
racy, so  as  to  produce  the  disease  with  varying  grades  of  intensity — with 
paralyses  or  without,  \\\i\\  constitutional  symptoms  or  with  only  slight  local 
infiltration.  What  is  still  more  im[)ortant,  he  has  been  able  to  cure  already 
infected  guinea-pigs  by  inoculation  with  the  blood  of  animals  rendered 
immune  by  previous  inoculation.  This  occurs  even  w\{\\  the  inoculation 
made  at  some  distance  from  the  local  lesion. 

Behring  and  Kitasato  have  shown  that  in  rabbits  the  action  of  the  attenu- 
ated diphtheritic  virus  destroys  the  toxines  formed  by  the  bacilli,  rather  than 
the  bacilli  themselves. 

According  to  recent  experiments  of  D'Espine,  the  bacillus  diphtheria;  is 
killed  by  local  applications  of  aqueous  solutions  of  the  strength  of  1  :  8000 
for  corrosive  sublimate,   1  :  2000   for  salicylic  acid,  and    1  :  oO   for  carboli<- 

acid. 

The  bacilli  still  live  at  temperatures  below  that  of  the  body,  even  at  68°  F. 
Boiling  destroys  them.  They  thrive  and  multiply  in  milk.  They  preserve 
their  vitality  for  four  or  five  months  or  more  in  dried  membrane.  C'ultures 
of  bacilli  have  been  kept  for  sixteen  months  without  losing  their  virulence. 
A  brush  used  to  swab  the  throat  of  a  diphtheritic  child  was  put  aside  in  a 
drawer  unclcaned  :  after  four  years  it  was  taken  out  and  infected  a  man  who 
used  it.  In  a  Normandy  village,  twenty-three  years  after  an  cpitlcmic  of 
diphtheria,  some  of  the  bodies  of  those  who  died  of  the  disease  were  exhumed, 
and  an  epidemic  at  once  broke  out,  first  among  those  wIk.  opened  the  graves, 
and  extended  to  others  (Sevestre). 

Diphtheria  in  vl?i/ma/.s.— l)i|>hth<  ria   is  common    among   <vr(aiu  domesti<- 
animals,  such  as  fowls,  pigeons,  calves,  cows,  pigs,  and  especially  cats,  aiu' 
may  be  inoculated   in  >Iie<|>.     'V\\vy  ac(|uire  a   false  niend)rane  in   the  throat 
with  constitutional  symptoms,  mid  various  l.Mcilli   are   f..nnd  at  tlir  site  of  th( 


w 


376  DIPHTHERIA. 

inflammation.  These  bacilli  are  not  in  every  case  identical  with  the  Klebs- 
Loffler  bacillus.  In  birds,  at  least,  the  bacilli  are  different,  but  it  is  highly 
probable  that  true  diphtheria  may  be  transmitted  from  cats  to  man,  and  con- 
versely. In  cats  the  disease  principally  affects  the  lungs  and  bronchi.  Filthy 
stables,  dirty  poultry-yards,  and  dove-cotes  favor  the  spread  of  diphtheria 
among  domestic  animals. 

It  is  claimed  by  Power  and  others  that  bovine  diphtheria  can  be  transmitted 
to  man  through  infection  of  the  milk  by  an  eruptive  disease  of  the  udders, 
and  cows  inoculated  under  the  shoulder  with  diphtheritic  microbes  exhibit  the 
germs  in  their  milk  after  developing  local  lesions  of  the  udders.  Transmission 
of  diphtheria  to  man  through  milk  is  certainly  rare,  if  it  be  possible.  Roux 
and  Yersin  have  isolated  a  microbe  which  excites  diphtheria  in  fowls,  rabbits, 
etc.,  and  have  also  separated  from  it  a  toxine  which  when  injected  causes 
asphyxia  and  paralysis  in  those  animals. 

Pseudo-Diphtheria. — Some  authors  are  disposed  to  describe  two  varieties 
of  diphtheria — one  accompanied  and  occasioned  by  the  Klebs-Loffler  bacillus, 
and  the  other  due  to  some  different  virus  or  germ  (possibly  the  streptococcus 
pyogenes).  The  latter  variety  they  call  "  pseudo-di])htheria."  Prudden  has 
recently  made  exhaustive  researches  in  cases  of  diphtheritic  inflammation 
occurring  in  connection  with  measles,  scarlatina,  etc.,  in  order  to  determine 
the  character  of  the  bacilli  present.  In  such  cases  he  failed  to  find  the 
Klebs-Loffler  bacillus,  although  he  obtained  a  streptococcus.  He  concludes, 
therefore,  that  the  latter  germ  is  the  cause  of  these  secondary  cases  of 
diphtheria. 

The  statements  regarding  the  etiology  of  pseudo-diphtheria  and  the  germ 
or  germs  associated  with  it  are  very  conflicting,  and  further  research  will 
doubtless  throw  much  light  upon  the  subject.  Abbott^  concludes  a  report  of 
a  recent  investigation  of  this  question  by  saying  :  "  From  these  observations 
we  feel  justified  in  agreeing  with  the  opinion  that  has  been  advanced  by  other 
observers,  particularly  Hoffmann  and  Roux  and  Yersin,  that  under  varying 
conditions  the  virulence  of  the  true  diphtheria  bacillus  may  be  observed  to 
fluctuate  in  the  degree  of  its  intensity — at  one  time  })ossessing  the  property  in 
a  high  degree,  at  another  presenting  a  decided  attenuation,  and  not  unfre- 
quently  a  complete  absence  of  pathogenic  power." 

The  pseudo-diphtheria  germ  has  been  found  in  the  pharynx  in  healthy 
children. 

In  pseudo-membranous  angina,  occurring  in  connection  with  scarlatina,  a 
streptococcus  is  found,  but  the  true  bacillus  diphtherife  is  absent.  Germs  are 
also  found  in  inflamed  conditions  of  the  mucous  membrane  accompanying 
measles  and  erysipelas,  but  the  Klebs-L5ffler  bacillus  occurs  only  in  diph- 
theria. 

False  membrane  closely  resembling  diphtheritic  membrane,  excepting  the 
absence  of  the  diphtheria  bacillus,   is  formed  on  mucous  surfaces  after  the 
application  of  various  irritants,  such  as  hot  steam,  cantharis,  strong  corrosive 
'  Johns  Hopkins  Hospital  Bulletin,  vol.  ii.  No.  17,  p.  146. 


ETIOLOGY.  Til 

sublimate,  arsenic,  ammonia,  etc.  Hnebner  has  shown  that  a  false  membrane 
may  even  form  as  a  result  of  mechanical  obstruction  to  the  local  vascular 
supply.  Hence  the  presence  of  the  germ  of  diphtheria  is  not  essential  for  the 
production  of  a  false  membrane. 

Much  of  this  bacteriological  work  is  so  recent  that  it  is  both  difficult  and 
unwise  to  adopt  positive  conclusions  from  it  until  further  evidence,  which  is 
now  being  diligently  sought,  shall  be  brought  to  light. 

The  habitat  of  the  microbe  when  outside  of  the  body  is  not  known,  but  it 
is  believed  to  live  in  surface  soil  which  is  contaminated  with  organic  matter. 
It  is  known  to  grow  on  excretory  refuse. 

Mode  of  Infection. — Infection  is  not  believed  to  occur  through  the  aliment- 
ary canal.  Some  observers  claim  that  it  is  possible  for  the  diphtheritic  virus 
to  enter  the  lungs  by  inhalation,  and,  being  absorbed  by  the  pulmonary  ves- 
sels, develop  constitutional  symptoms  before  the  local  lesion  in  the  throat  is 
manifest ;  but  the  weight  of  evidence  is  decidedly  in  favor  of  regarding  the 
mucous  membrane  of  the  upper  air-passages  as  the  common  site  of  infection. 

It  is  not  proved  definitely  that  in  man  an  abraded  surface  is  necessary  for 
the  virus  to  find  lodgment,  but  many  believe  that  a  diseased,  denuded,  or 
catarrhal  mucous  surface  is  essential  in  man,  as  it  is  for  inoculation  in  the 
lower  animals.  It  is  certain,  iiowever,  that  diseased  mucous  surfaces  are 
far  more  susceptible  to  the  infection  than  healthy  surfaces.  Moreover,  it  is 
very  easy  to  overlook  slight  abrasions  after  the  local  symptoms  have  become 
manifest. 

The  mode  of  infection  is  cither  by  direct  contact  of  shreds  of  diphtheritic 
membrane,  or  more  frequently  through  infected  air,  or  tlirough  the  agency  of 
various  fomites,  such  as  contaminated  clothing,  iiandkerchiefs,  toys,  books,  etc. 
Shreds  of  fibrin  are  frequently  expelled  with  a  violent  cough,  and  if  they  hap- 
pen to  lodge  in  the  eye  or  mouth  of  the  physician  or  nurse,  they  seldom  fail 
to  infect.  Many  valuable  lives  have  been  sacrificed  in  this  way.  Physicians 
have  lost  their  lives  from  endeavoring  to  clean  out  a  tracheotomy-tube  by 
sucking  a  plug  of  mucus  or  memlirane  from  it  which  threatened  to  suffocate 
the  patient.     The  disease  has  been  transmitted  by  kissing. 

Diiihtheria  is  highlv  contagious  within  the  immediate  neighborhood  of  the 
patient,  but  the  radius  of  direct  contagion  is  limited  to  a  fi'W  feet.  For  this 
reason  a  diphtheritic  patient  may  be  perfectly  well  treated  at  home  without 
endant^erint'-  other  members  of  the  household,  provide<l  the  nccessarv  local 
quarantine  can   i)e  established  and   rigidly  enforced. 

The  bacilli  cling  to  different  objects  with  great  tenacity,  and  in  this  way 
are  conveyed  for  consideral)le  distances  while  preserving  their  vitality. 
Moisture  is  more  favorable  to  their  growth   tlmii   dryness. 

The  spread  of  di|)litlieii:i  is  greatly  favoretl  hy  bad  liygienie  ((inditions, 
such  as  are  found  in  dump,  daik  houses,  miwholesome  cellars,  the  |)re>eiiee 
of  sewer-gas,  et*-.  There  is  some  dduht  :is  lu  Ikiw  far  the  hitter  is  directly 
concerned  in  the  jn-opiigation  of  diphtheritic  virus.  Imt  it  is  ccrlaiidy  tnu- 
that    persons    who    live    nndei-    nnra\<ir:ii)l<'    hynicnie    eonditiuns  and     inhale 


378  DIPHTHERIA. 

sewer-gas  acquire  anseniia  and  a  general  lowering  of  vitality  that  makes 
them  susceptible  to  any  contagion, 

Fiftv  dit!erent  epidemics  of  diphtheria  occurring  in  various  localities  in 
England  were  recently  investigated  with  great  care,  and  in  only  four  could  the 
outbreak  be  traced  to  direct  contagion.  The  rest  were  all  connected  with  foul 
cesspools,  deficient  drainage  and  sewerage,  or  the  proximity  of  dirty  animals 
and  decomposing  organic  matter,  such  as  manure. 

Diphtheria  prevails  in  isolated  rural  districts  as  well  as  in  towns.  In  this 
countrv  it  has  often  appeared  unaccountably  in  a  new  and  sparsely-settled 
frontier  village  or  in  an  isolated  family  on  a  ranch.  There  is  a  possibility  of 
its  having  been  communicated  by  domestic  animals,  but  as  yet,  excepting  per- 
haps in  the  case  of  cats,  this  is  by  no  means  proved. 

The  ignorance  of  many  persons  regarding  the  contagion  of  diphtheria  is 
a  factor  in  extending  an  epidemic.  It  is  often  propagated  through  clothing 
Avashed  or  manufactured  in  a  room  where  a  diphtheritic  patient  lies.  Succes- 
sive cases  may  occur  among  the  members  of  the  same  family  at  intervals  of  a 
few  weeks. 

Age. — Diphtheria  is  principally  a  disease  of  childhood,  for,  although  it  may 
occur  at  any  ])eriod  up  to  fifty  years  of  age,  the  susceptibility  to  it  diminishes 
rapidly  after  youth,  and  it  is  commonest  under  ten  years  of  age,  the  majority 
of  cases  occurring  between  the  second  and  seventh  years.  It  is  very  rare  in 
early  infancy,  although  it  has  been  acquired  by  the  newborn  (Eichhorst). 

8ex. — Diphtheria  is  practically  uninfluenced  by  sex.  Some  authors  say  that 
it  is  slightly  more  common  among  females. 

Climate. — Diphtheria  is  found  in  all  climates,  but  less  frequently  in  the 
tropics  than  in  cold  and  temperate  regions.  It  is  a  common  disease  throughout 
the  United  States  and  Europe.  In  certain  localities  it  is  endemic,  and  at  inter- 
vals becomes  epidemic.     It  is  favored  by  cold  and  damp  weather. 

Immunity. — One  attack  of  diphtheria  does  not  confer  immunity ;  in  fact,  a 
patient  may  have  several  attacks,  and  may  even  be  reinoculated  during  con- 
valescence by  germs  which  have  accumulated  in  the  vicinity  from  lack  of 
cleanliness. 

Season. — In  the  United  States  diphtheria  is  more  common  in  the  winter  and 
spring  than  at  other  seasons. 

Associated  Diseases. — Other  acute  diseases  affecting  the  throat  are  ver}' 
commonly  associated  with  diphtheria.  Foul  effluvia  from  excrement  and  sewer- 
gas  doubtless  beget  in  some  cases  sore  throat  which  is  not  diphtheritic,  but 
laryngitis,  tonsillitis,  pharyngitis,  and  quinsy  are  all  apt  to  prevail  during  an 
e])idomic  of  diphtheria,  and  to  originate  in  like  conditions  of  environment, 
although  there  is  no  anatomical  relation  between  them. 

Epidemics  of  diphtheria  sometimes  are  related  to  the  prevalence  of  other 
diseases ;  thus,  they  are  n])t  to  follow  cjiidemics  of  measles  or  to  accom])any 
scarlatina  or  variola.  Di])litlieria  and  typhoid  fever  are  often  prevalent  simul- 
taneously in  the  same  localities.     Taylor^  relates  a  case  in  which  scarlatina, 

'  Lancet,  Aug.  2.  18<)0,  p.  232. 


MORBID    AX  ATOMY.  379 

measles,  and  diphtheria  occurred  simultaneously.  Erysipelas  sometimes 
occurs  with  diphtheria  in  the  same  individual ;  and  such  cases  become 
rapidly   malignant. 

Morbid  Anatomy. — Since  diphtheria  usually  attacks  the  upper  air-pas- 
sages, the  mucous  membranes  which  are  most  frequently  affected  are  those  of 
the  tonsils,  soft  j^alate,  pillars  of  the  fauces,  posterior  pharyngeal  wall,  larynx, 
trachea,  and  nose.  In  addition,  the  diphtheritic  inflammation  may  involve  the 
gums,  root  of  the  tongue,  buccal  Avail,  asophagus,  fundus  of  the  stomach,  rec- 
tum, vagina,  the  puerperal  uterus,  and  open  wounds  on  the  surface  ol"  the  body 
or  an  abraded  surface  like  a  blister  or  leech-bite. 

Di})htheritic  inflammation  is  characterized  by  the  jjroduction  of  tibrinous 
exudation.  The  stroma  of  the  mucous  membrane  is  filled  with  more  or  less 
disintegrated  leucocytes,  pus,  and  fibrin,  which  also  appear  on  its  free  surface. 
There  is  coagulation-necrosis  of  the  epithelium,  which  is  shrivelled  and  dis- 
torted in  form,  with  indistinct  nuclei  or  none  at  all.  The  false  or  pseudo- 
membrane  is  composed  of  flaky,  necrosed  ej)ithelium,  disintegrated  leucocytes, 
pus,  fibrin,  and  bacilli  in  varying  relative  amount,  and  sometimes  red  blood- 
cells.  The  mucous  membrane  beneath  is  more  or  less  necrotic,  and  the  sub- 
mucous layer  is  also  necrotic  in  bad  cases.  There  is  hyjier.Tmia,  and  often 
tumefaction  of  the  surrounding  mucous  surface,  which  secretes  a  muco-puni- 
lent  exudation.  The  redness  of  the  surrounding  area  is  often  distinctly  locnl- 
ized,  and  it  may  be  confined  to  one  side  of  the  throat. 

The  fibrin  is  supposed  to  be  derived  mainly  from  inllammatory  c\udati(ni 
which  transudes  from  the  capillary  walls,  and  which  is  coagulated  by  ferment 
derived  from  disintegrated  leucocytes  (Weigert).  The  cell-bodies  may  a.ssist  in 
forming  the  fibrin,  but  the  epithelial  cells  probably  do  not  play  any  very  active 
role  in  the  inflammation,  although  some  pathologists  have  claimed  that  they  arc 
altered  in  shape  and  produce  branching  fibrillje.  As  the  inflammation  subsides 
the  necrosed  portion  of  mucous  membrane  sloughs  off*,  and  the  epithelial  sur- 
face is  restored  by  outgrowth  from  neighboring  cells.  If  there  has  been  deep 
involvement  of  the  raucous  and  submucous  layers,  cicatrices  may  be  formed, 
such  as  sometimes  occur  in  the  tonsils.  Otherwise,  after  the  false  membrane 
has  sloujrhed  off,  the  mucous  surface  is  left  clean  and  smooth.  Several  succes- 
sive  membranes  may  form  at  the  same  site,  and  this  is  especially  the  case  when 
thev  are  fi)rcibly  strippe(l  off.     Tho  process  of  exi'oliation  occupies  several  day>. 

The  Klebs-L«jffler  bacilli  are  found  scattered  through  the  meshes  of  the 
fibrillate<l  fibrin  <.r  in  granular  fii)rin.  With  them  are  often  seen  other  varieties 
of  microbes,  especially  streptococci  and  sta|)hylococci,  occurring  in  eohmics  or 
isolated.  These  other  forms  of  microbes  may  be  found  situated  more  deeply 
than  the  baeilhis  di])htherise. 

The  inflammation  affects  the  imio.us  memi)rane  with  :iii  int<-n>ity  varying 
from  congestion,  with  a  thin,  grayish  or  yelIowi>h  lihu  spread  over  the  surface 
in  isolated  irn-iil:ir  patches  or  in  a  single  layer,  up  to  the  forniMlic.ii  of  a  thick, 
firmly  attached  pseudo-membrane  covering  a  tinnelied  nnicous  surface  with 
more  or  less  necrosis  of  the  (Iccpii'  layers. 


380  DIPHTHERIA. 

The  3Iembrane. — The  character  of  the  pseudo-membrane  varies  somewhat 
with  the  structure  of  the  particular  raucous  membrane  aifected.  It  is  apt  to  be 
more  fibrinous  and  more  firmly  adherent  to  a  surface  covered  originally  by 
squamous  cells  instead  of  by  ciliated  or  other  forms  of  epithelium. 

The  membrane  is  of  a  grayish-white  color,  and  if  superficial  can  be 
stripped  off,  and  is  found  to  be  elastic  and  firm.  Shaken  in  water,  it  does  not 
disintegrate.  It  swells  in  acetic  acid.  If  the  deeper  tissue  be  involved,  the 
membrane  is  more  adherent,  and  attempts  at  its  removal  may  lacerate  the  sur- 
face and  produce  bleeding.  This  is  especially  the  case  over  the  irregular  ton- 
sillar surfaces.  The  color  deepens  as  the  membrane  becomes  older.  It  grows 
yellowish,  and  may  be  streaked  with  red  from  admixture  of  blood,  or  it 
bec6mes  dark  brown.  It  may  soften  and  break  down  into  an  offensive, 
ichorous,  brownish  discharge.  After  death  it  is  apt  to  decompose  and  soften 
rapidly.  Very  rarely  the  membrane  may  be  absent,  in  which  case  the 
inflamed  surface  is  swollen  and  of   a  grayish-white  color  from  infiltration. 

When  the  pseudo-membrane  is  advancing  the  edges  are  thin,  and  they 
shade  into  the  surrounding  area  of  inflammation,  but  if  repair  is  about  to  take 
place,  the  patches  may  thicken  or  wrinkle  at  their  edges,  which  become  dis- 
tinctly separated  from  the  mucous  membrane.  The  pseudo-membrane  is 
loosened  by  effusion  of  serum  and  immigration  of  leucocytes  beneath,  and  by 
ulcerative  process,  so  that  it  sloughs  off'  in  fragments  or,  less  often,  as  one 
piece. 

Lesions  of  the  mucous  membrane  undoubtedly  aid  the  spread  of  the  virus, 
and  hence  the  injurious  effect  of  forcibly  stripping  off  the  false  membrane  and 
exposing  raw  bleeding  surfaces.  It  is  said  that  the  reason  the  tonsils  are  more 
frequently  the  starting-point  of  diphtheritic  inflammation  is  partly  because  of 
their  prominence,  but  also  on  account  of  the  fact  that  their  epitlielial  cover- 
ing is  not  always  everywhere  continuous,  and  hence  the  virus  has  easier 
access  to  their  mucous  membrane.  The  virus  may,  however,  undoubtedly 
attack  a  mucous  membrane  in  which  no  abnormality  is  discoverable,  possibly 
because  a  slight  abrasion  is  so  readily  overlooked  after  the  local  inflammation 
has  begun. 

The  heart  shows  more  or  less  fatty  infiltration  between  the  muscular  fibres 
and  around  the  blood-vessels.  The  muscle-fibres  themselves  may  have  swollen 
nuclei.     Both  ventricles  are  often  dilated. 

Tlie  epiglottis  may  be  congested,  but  it  is  exceptional  for  it  to  become 
sufficiently  oidematous  to  impede  respiration. 

The  bronchi  may  appear  normal  or  present  a  catarrhal  or  croupous  inflam- 
mation. The  diphtheritic  membrane  may  extend  over  their  mucous  surfaces 
down  to  the  bronchioles.  There  may  be  broncho-pneumonia  or  lobar  pneu- 
monia from  inhalation  of  shreds  of  fibrin  and  putrid  material  from  sloughs  in 
the  mouth.  If  death  has  occurred  from  suffocation,  the  lungs  may  be  slightly 
emphysematous  (Flint). 

The  lymphatic  glands  near  the  site  of  the  local  inflammation  are  the  seat 
of  hyperplasia.     The  lymphatic  glands  at  the  angle  of  the  jaw  and  in  the  neck 


SVMPTOMA  rOLOG  Y.  381 

are  most  apt  to  be  affected,  esj)ecially  if  the  nares  are  involved.  The  variou^ 
salivary  glands  may  also  be  enlarged.  As  a  rule,  the  glandular  swelling  sub- 
sides without  suppuration.  Sometimes  the  periglandular  tissue  becomes  infil- 
trated and  greatly  swollen. 

In  malignant  eases  there  is  deep  sloughing,  or  even  gangrene,  at  the  site  of 
local  inflammation,  and  there  mav  be  haemorrhages  from  the  various  mucous 
membranes,  or  general  purpura  and  parenchymatous  degeneration  of  viscera. 
The  spleen  may  be  somewhat  enlarged,  and  both  spleen  and  liver  may  be 
hyper?emic.  The  blood  will  coagulate  poorly,  and  it* is  very  dark.  Ante- 
mortem  heart-clots  and  venous  thrombi  may  occasionally  form.  Small  liaMuor- 
rhages  have  been  found  in  the  meninges  of  the  brain  and  spinal  cord. 

Symptomatology. — The  period  of  incubation  of  diphtheria  may  be  very 
brief,  lasting  only  twenty-four  or  thirty-six  hours,  or  it  may  occupy  a  week. 
It  will  depend  somewhat  upon  the  severity  of  the  epidemic,  the  incubation 
period  being  shorter  where  the  poison  is  concentrated  or  propagated  l)y 
experimental  inoculation. 

The  symptoms  are  both  local  and  constitutional,  and  they  may  vary  con- 
siderably, for  mild  and  malignant  types  may  develop  side  by  side.  There  is 
no  definitely  fixed  relation  between  the  general  symptoms  and  the  intensity  of 
the  localized  inflammation. 

Prodrornafa. — Diphtheria  usually  commences  with  certain  prodromal  symjv 
toms,  such  as  malaise,  anorexia,  headache,  and  sometimes  nausea  and  vomiting. 
There  may  be  chilly  sensations,  but  a  distinct  chill  is  not  common. 

Invasion  and  Course. — In  a  few  hours  the  patient  com})lains  of  slight 
dryness  and  soreness  of  the  throat  on  swallowing,  but  the  pain  is  seldom 
as  acute  as  in  tonsillitis.  There  may  be  pain  also  on  speaking,  or  aphonia. 
Sometimes  the  throat  is  slightly  amesthetic.  There  is  a  feeling  of  increas- 
ing weakness  and  more  or  less  general  muscular  soreness.  There  is  a 
slight  rise  of  temperature.  Upon  examining  the  throat  the  tonsils  are 
found  slightly  swollen  and  reddened,  and  there  may  be  hypenemia  of 
the  pillars  of  the  fauces  and  uvula.  One  or  two  small  grayish  or  yel- 
lowish sj)Ots  will  be  observed  upon  the  inner  surface  of  one  or  both  tonsils. 
They  are  covered  by  a  thin,  firmly-adherent  membrane.  The  spots  remain 
inicliaii<red  for  a  dav  or  two,  and  in  the  mihlest  cases  only  the  tonsils  are 
affected.  In  other  cases  the  spots  jjromptly  coalesce,  and  a  continuous 
membrane  is  formed  which  covers  the  whole  of  the  tonsils,  stretching  up 
over  the  fiinces  and  soft  palate.  There  is  more  or  less  redness  and  swelling 
of  the  adjacent  mucous  membrane,  and  there  may  be  small  ecchymoses  in  it. 
Sometimes  there  is  no  pain  at  all  in  the  throat,  even  in  bad  cases,  or  (1h  re  is 
moderate  pain,  dysphagia,  and  thirst.  Tlic  constitutional  symptoms  continue. 
The  pulse  becomes  more  n\\m\,  120  or  140,  and  very  i'rv\Av.  The  fir^t  s-.tnid 
of  the  heart  is  indistinc-t.  The  |>a(i<-nt  i'vr\>  ill  and  looks  pallid.  The  Inn- 
perature  mav  rise  in  a  day  or  two  to  KM.'/-'  l'\,  or  even  liiglirr.  bin  in  many 
cases  it  remains  below  102. r/Mlirouglioiit  1  In- disease.  TIicwIk.Ic  c-ourse  of 
the  fever  is  iire.rular.     The  i-espiralioii  is  not  |.,irli<'ularly  all'cctcd,  but  it  may 


382 


DIPHTHERIA. 


he  quickened.  The  hreath  is  foetid.  The  tongue  is  coated  and  sometimes 
swollen.  There  is  complete  anorexia,  and  nausea  may  be  present.  The 
bowels  are  costive.  There  is  more  or  less  swelling  of  the  cervical  lymphatic 
glands,  with  pain  or  soreness  on  opening  the  jaw,  which  is  sometimes  felt  also 
in  the  ears.     The  glandular  enlargement  is  usually  symmetrical. 

By  the  second  or  third  day  albumin  may  be  found  in  the  urine,  which  may 
become  scanty  and  high  colored,  or,  in  other  cases,  may  still  appear  normal  to 
the  eye.  After  a  week  or  ten  days  the  throat  begins  to  improve,  the  constitu- 
tional symptoms  abate,  and  the  patient,  somewhat  enfeebled,  slowly  convalesces; 
or  the  disease  proceeds  to  a  fatal  issue,  in  which  case,  instead  of  the  membrane 
ceasing  to  extend,  it  advances,  passing  either  upward  or  downward. 

If  the  membrane  reaches  into  the  vault  of  the  pharynx,  it  passes  the 
posterior  nares  and  comes  forward  to  fill  the  nasal  cavities.  There  may  be 
deafness  from  swelling  of  the  orifices  of  tlie  Eustachian  tubes  or  extension  of 
the  inflammation  into  them. 

When  the  nares  are  involved  there  will  be  a  thin,  muco-purulent  discharge 
from  the  nose,  which  may  excoriate  the  septum,  alse,  and  upper  lip.  It  later 
becomes  brown,  and  is  frequently  hsemorrhagic  and  extremely  offensive  in 
odor.  Tiiere  are  snuffles  and  sneezing,  and  young  infants  cannot  suckle,  and 
must  be  fed  with  a  spoon.  Mouth-breathing  becomes  necessary.  The  nose 
itself  and  the  upper  lip  become  somewhat  red  and  swollen.  The  glands  at 
the  angle  of  the  jaw  and  the  submaxillary  glands  become  enlarged  and  tender, 
owing  to  their  connection  with  the  Schneiderian  lymphatic  vessels.  This  gland- 
ular swelling  is  often  the  first  sign  of  nasal  diphtheria.  Sometimes  the  con- 
nective tissue  between  the  glands  is  infiltrated,  and  the  entire  neck  may  be 
greatly  swollen,  so  as  to  interfere  with  the  motion  of  the  head.  In  bad  cases 
the  inflammation  may  extend  along  the  lachrymal  ducts  and  reach  the  con- 
junctivae, which  become  red,  swollen,  watery,  and  finally  are  covered  by 
pseudo-membrane.  There  may  be  uncontrollable  epistaxis.  In  other  cases 
the  inflammation  extends  along  the  Eustachian  tube,  and  finally  excites  an 
otitis  media,  with  perforation  of  the  tympanum  and  other  grave  lesions. 

Should  the  membrane  spread  downward,  as  is  very  frequently  the  case, 
the  larynx  is  lined  with  pseudo-membrane  which  obstructs  respiration.  The 
first  symjitom  noticed  is  hoarseness,  which  occurs  between  the  third  and 
sixth  days.  Then  the  breathing  becomes  quick  and  shallow  or  noisy  and 
stertorous.  There  may  be  aphonia.  There  is  a  peculiar  characteristic 
harsh-ringing,  croupy  cough.  The  patient  becomes  cyanotic,  cold,  anxious, 
and  sits  up  or  tosses  about  in  bed,  gasping  for  breath,  with  the  head 
extended,  the  mouth  open,  the  alae  nasi  working  vigorously,  and  all  the 
accessory  respiratory  muscles  called  into  action.  Owing  to  the  impeded 
entrance  of  air,  the  supraclavicular  spaces  and  the  lower  intercostal  spaces 
are  sunken  by  atmospheric  pressure  during  inspiration.  Breathing  is  super- 
ficial, rapid,  and  irregular.  The  patient  may  cough  up  pieces  of  membrane 
and  secure  temporary  relief,  but  the  dyspnoea  returns  promptly,  as  new  mem- 
brane rapidly  forms.     A  new  membrane  sometimes  appears  in  half  an  hour. 


SYMPTO.VA  rOLOa  Y.  383 

The  cougli  may  ho  paroxysmal  troin  a  t'lUR'tiuiial  spasm  of  tlic  vot-al  cords. 
Salivation  may  be  present,  and  there  is  repugnance  to  food  of  anv  kind.  In 
bad  cases  the  vomitintj  may  continue  and  be  accompanied  by  diarrhoea. 

AVhile  the  local  inflammation  is  augmenting  the  constitutional  symptoms 
become  very  unfavorable.  The  pulse  grows  more  and  more  rapid,  feeble,  and 
irregular.  There  is  increasing  pallor,  and  sometimes  a  cold  perspiration  covers 
the  body.  The  fever  continues  or  diminishes.  The  albuminuria  increases; 
granular  and  epithelial  casts,  with  sometimes  a  few  red  blood-cells,  appear  in 
the  urine.  The  prostration  is  extreme.  Neurotic  symptoms  are  not  prominent, 
and  the  mind  is  usually  clear,  but  a  typhoid  condition  witli  delirium  may 
ensue.  Young  children  sometimes  have  mild  convulsions.  Paralysis  may 
ajipear  at  this  time,  involving  the  uvula,  nuisclcs  of  deglutition,  or  one  or  more 
of  the  extremities.  Finally  death  results  from  suffocation  unless  tracheotomy 
or  intubation  be  performed  [vide  infra),  or  from  asthenia  and  cardiac  par- 
alysis. 

Special  Symptoms. — The  temperature  may  remain  low  throughout  the 
disease,  or,  beginning  high  with  an  initial  angina,  it  may  fall,  later  on,  to 
101°  F.,  with  increasing  blood-poisoning.  A  continued  high  temperature  is 
not  at  all  characteristic  of  diphtheria. 

The  dyspnoea  may  have  several  causes.  It  may  be  due  to  obstruction  in  the 
larvnx  from  swelling  and  accumulation  of  thick  pseudo-membrane  or  to  a 
piece  of  membrane,  partly  detached,  which  acts  like  a  valve,  flapping  to  and 
fro  with  the  respiratory  movements  and  closing  the  glottis  in  inspiration. 
Again,  it  may  be  due  to  alteration  or  disintegration  of  the  red  blood-disks, 
and  their  inability  to  convey  oxygen,  produced  by  a  toxic  condition  of  the 
system.  It  may  arise  from  heart  failure  and  impeded  pulmonary  circulation, 
or  it  may  occur  from  sudden  spasm  or  paralysis  of  one  or  both  vocal  cords. 

When  death  ensues  from  extreme  dyspnoea  and  suttbcation,  the  mind 
becomes  dull  or  there  is  coma,  followed  by  convulsions  and  o})isthotonos. 
The  heart  becomes  very  feeble  and  the  cardiac  sounds  are  inaudible;  the 
radial   pulse  cannot   be  felt.     The  surface  of  the  body  is  cold,   moist,   and 

blue. 

The  urine  presents  the  features  commonly  found  in  acute  febrile  disease. 
The  urates  are  increased,  the  color  is  deeiXMied  or  normal,  the  specific  gravity 
is  raised,  and  the  quantity  is  lessened.  There  is  more  or  less  albumin  in  over 
50  per  cent,  of  the  cases.  There  are  epithelial  and  gramilar  casts,  and  some- 
times a  few  blood-cells.  Albuminuria  is  rare  in  the  first  day  or  two.  It  usu- 
ally occurs  between  the  third  or  flfdi  and  the  tenth  day.  It  may  be  (luc 
to  acute  nephritis  or  to  toxines  which  modily  the  albuminous  ingredients 
of  the  tissues  and  ijlood,  or    it  may  occur    late    in   the  disease    from    renal 

congestion    in   connection   with   dyspnoea  :iiid    faiihy    :ieiati..n    ..f   tli.>    bl 1. 

In  the  latter  case  it  sometimes  disapjicars  aCl-r  iiitul):iti.iii  m-  tracheotomy. 
The  intensitv  of  the  all)nminiiriM  is  ni.t  to  .•onfuiiM  to  the  severity  of  the 
disease.  The  albuminuria  usually  subsides  as  the  symptoms  abate,  and  the 
parenchvmatous  nephritis  seldom   be...iues  .•hroiiic.      It   is  exceptional   for  it 


384  DIPHTHERIA. 

to  occasion  urremia  or  oedema.     When  acute  interstitial  nephritis  occurs  there 
is  great  infarction  of  the  stellate  veins  (Synipson). 

The  pulse  is  uin'formly  rapid.  In  infants  it  often  reaches  180  or  200 ; 
in  older  children,  140  or  150.  It  may  drop  suddenly  below  the  normal, 
which  is  always  a  serious  indication  of  increasing  cardiac  weakness.  There 
is  often  sudden  cardiac  paralysis  during  convalescence,  which  may  appear 
after  the  patient  has  been  walking  about.  The  right  side  of  the  heart 
may  become  suddenly  dilated,  with  feeble  sounds,  irregular  action,  and 
absent  impulse. 

Malignant  Cases. — In  any  severe  epidemic  of  diphtheria,  and  some- 
times sporadically,  a  certain  number  of  cases  assume  a  distinctly  malignant 
type.  They  may  be  of  two  classes,  in  both  of  which  the  invasion  is  acute, 
with  rigors,  headache,  vomiting,  and  sudden  prostration. 

In  the  first  variety  the  system  is  overwhelmed  with  diphtheritic  poison,  so 
that  death  occurs  in  two  or  three  days,  from  disintegration  of  the  blood  and 
heart-failure,  before  the  membrane  has  had  time  to  extend.  In  these  cases 
there  is  somnolence,  stupor,  or  delirium,  the  heart-action  rapidly  fails,  the 
skin  is  cold  and  clammy,  and  there  may  be  ecchymoses  in  it. 

In  the  second  variety  the  membrane  spreads  very  rapidly,  simultaneously 
covering  a  large  surface,  and  laryngeal  and  bronchial  inflammations  quickly 
supervene.  In  the  worst  cases  the  entire  tonsils,  fauces,  uvula,  buccal  cavity, 
posterior  pharynx,  larynx,  and  nasal  cavities  are  covered  with  thick,  brown, 
foul-smelling  membrane.  Extensive  sloughing,  and  even  gangrene,  may 
result.  Such  cases  are  almost  hopeless  from  the  commencement,  and  every 
eifort  must  be  made  to  quarantine  and  disinfect  them. 

As  a  rule,  adults  are  more  apt  to  suffer  from  severe  constitutional  symp- 
toms, and  children  from  laryngeal  extension  of  the  inflammation.  Adults 
often  die  while  there  is  comparatively  little  membrane  present. 

Duration. — Diphtheria  is  a  disease  without  definite  duration.  The  average 
case  lasts  about  ten  days  or  a  fortnight.  Very  mild  cases  may  recover  in  a 
week,  while  others,  more  severe,  last  three  or  four  weeks.  There  are  cases 
which  continue  for  two  months  without  the  throat  becoming  entirely  well, 
although  the  constitutional  symptoms  may  abate.  Bacilli  have  been  found  by  . 
Klebs  lingering  in  the  throat  after  the  false  membrane  had  disappeared. 

Terminations. — Diphtheria  may  end  in  recovery,  or  death  ensues  from  one 
or  other  of  the  following  causes :  extension  to  the  larynx  and  suffocation  by 
occlusion ;  laryngeal  spasm  or  jjaralysis ;  asthenia ;  cardiac  paralysis,  and 
syncope. 

Complications. — The  two  most  frequent  complications,  which  are  also  the 
most  severe,  are  albuminuria  and  paralysis.  They  are  so  frequent,  in  fact — 
especially  the  albuminuria — as  to  be  regarded  by  some  authors  as  symptoms. 
On  the  other  hand,  they  may  occur  later  as  sequelae. 

Endocarditis  is  a  rare  and  fatal  conq^lication  of  diphtheria. 

A  rare  complication  is  the  invasion  of  the  conjunctiva  by  the  diphtheritic 
inflammation.     This  is  always  an  exceedingly  grave  accident,  and   it  may 


D  UliA  TIOX. — 9£Q  UEL^.  385 

result  in  the  destruction  of  the  cornea  inside  of  two  days,  with  u  total  loss 
of  vision. 

Fatal  epistaxis  or  severe  hremorrhages  from  the  diseased  mucous  surfaces 
are  unusual  complications.  Extreme  alterations  in  the  pulse-rate  on  either 
side  of  the  normal  may  occur,  but  a  very  slow  pulse  is  exceptional. 

Seqiielge. — The  scquelfe  of  dij)htheria  are  both  mild  and  severe,  and  they 
may  last  throughout  several  months.  Cougostion  of  the  fauces  and  tousillar 
hypertrophy  may  continue  for  some  time.  Tlie  uvula  is  often  hypertropiiicd, 
and  chronic  nasal  catarrh  may  be  instituted. 

The  paralyses  which  follow  diphtheria,  or  which  in  some  cases  appear  in 
connection  with  the  height  of  the  disease,  are  various.  They  are  connuoulv 
trophic  motor  paralyses,  but  may  be  both  motor  and  sensory,  and  com- 
monly occur  within  two  or  three  weeks  after  disappearance  of  the  throat 
symptoms. 

They  are  peculiar,  for  one  set  of  muscles  often  regain  their  function  while 
another  is  losing  it,  and  they  are  as  likely  to  occur  in  uiild  as  in  severe  cases. 
As  a  rule,  recovery  takes  place  in  from  six  to  eight  weeks,  but  some  cases  are 
protracted  for  a  year  or  two. 

The  tendon-reflexes  are  very  frequently  abolished,  and  the  normal  knee- 
jerk  may  be  absent  for  some  time.  Absence  of  pain  or  tenderness  along  the 
nerves,  such  as  occurs  in  multiple  neuritis,  is  noted. 

The  soft  palate  is  oftenest  affected.  It  hangs  loose,  is  insensitive,  and  the 
voice  becomes  nasal.  Occasionally  one-half  only  is  paralyzed,  and  it  is  drawn 
toward  the  opposite  side.  This  paralysis  may  occur  irrespective  of  any  iuflam- 
mation  of  the  uvula.  The  reflex  action  is  abolished.  The  tongue  and  j)har- 
vngeal  muscles  mav  be  involved. 

The  various  ocular  muscles  are  often  paralyzed,  giving  rise  to  loss  of 
accommodation,  double  vision,  or  strabismus.  One  or  both  vocal  cords  may 
be  paralvzed  'and  seriously  interfere  with  respiration.  The  diaphragm  aud 
intercostal  or  cervical  muscles  may  be  paralyzed.  Exceptionally  there  is 
paralysis  of  the  sphincters  of  the  bladder  and  rectum,  with  retention  of 
urine  and  faecal  incontinence.  There  may  be  loss  of  tendou-roflcx  at  the 
knee,  with  inco-ordi nation  in  gait  and  without  loss  of  muscular  ])(>wcr  in 
the  legs.  This  ataxia  is  accompanied  by  loss  of  sensation  in  the  feet  and 
legs,  by  swaying  of  the  erect  body,  and  loss  of  bahuicc  wlicn  the  eyes 
are  closed   (the   Romberg  symptom). 

The  legs  are  more  apt  to  be  paralyzed  than  the  arms.  Paralysis  of  the 
h(,'art  is  quite  frequent,  and  is  supposed  to  follow  degeneration  of  the  i-ardiac 
nerves  or  ganglia.  Various  forms  of  aufesthesia  aud  ilysiesthesia  are  some- 
times present. 

The  paralyses  are,  in  part  at  least,  due  to  degenerative  changes  in  the  periph- 
eral nerves,  though  in  some  c-ases  cent  ml  lesions  may  occur.  As  a  rule,  the 
iruiscles  sup])licd  by  the  afl'ected  nerves  do  n(»t  atrophy,  and  they  retain  their 
response  to  electric  stimulation,  both  galvanic  and  faradic. 

Some  one  of  these  forms  of  paralysis  occurs  in   10  per  cent,  of  eases  in  u 
Vol..  r.— 25 


386  DIPHTHERIA. 

bad  epidemic.  The  prognosis  is  generally  good  for  final  recovery  from  the 
paralysis  unless  the  muscles  of  respiration  or  deglutition  or  the  heart  are 
affected.  Chorea  and  epileptiform  attacks  have  been  observed  exception- 
ally, and  there  may  be  peripheral  hypersesthesia.  There  are  often  persist- 
ent anorexia  and  obstinate  anaemia. 

Diagnosis. — It  is  more  common  to  mistake  various  lesions  of  the  throat 
in  adults  for  diphtheria  than  to  overlook  diphtheria  when  once  fairly  estab- 
lished. Young  children,  however,  seldom  complain  of  the  throat  symptoms 
in  anv  manner,  and  their  throats  should  be  examined  as  a  matter  of  routine 
in  any  doubtful  illness.  Otherwise,  cases  of  diphtheria  may  advance  beyond 
•control  before  they  are  discovered. 

In  simple  inflammation  of  the  pharynx  and  in  follicular  tonsillitis,  as  com- 
pared with  diphtheritic  inflammation,  the  invasion  is  more  sudden,  the  tem- 
perature higher,  and  the  redness  of  the  throat  more  diffuse,  and  not  con- 
fined to  one  side,  as  is  often  the  case  in  commencing  diphtheria.  In  tonsillitis 
the  uvula  is  not  involved,  but  in  diphtheria  it  usually  is,  and  the  nasal  cavities 
may  be  also  affected.  Moreover,  in  follicular  tonsillitis  the  yellowish-white 
spots  can  often  be  removed  from  the  crypts  which  the  secretion  occupies,  and 
the  inflammation  frequently  abates  in  thirty-six  hours,  whereas  in  diphtheria 
it  continues  for  a  week  or  two.  A  doubtful-looking  layer  of  mucus  is  often 
removed  by  having  the  patient  gargle  the  throat  with  salt  water. 

Cases  of  difficult  diagnosis  occur  occasionally  from  the  fact  that  the  mem- 
brane is  concealed  by  originating  in  the  nares  or,  as  reported  by  Jacobi,  in  the 
trachea  before  other  surfaces  are  affected.  The  tracheal  origin  is  denied  by 
many  observers. 

There  are  cases  of  inflammation  of  mucous  surfaces  which  are  traumatic, 
and  which  closely  reseml)le  diphtheria  from  an  anatomical  standpoint,  except 
from  the  absence  of  bacilli — such  as  are  caused  by  irritating  substances  swal- 
lowed  or  inhaled  by  mistake,  as,  for  example,  chlorine,  ammonia,  live  steam, 
etc.  When  an  epidemic  originates  many  cases  occur  which  pass  undetected  as 
an  ordinary  "  sore  throat,"  and  their  real  nature  is  not  apparent  without  very 
careful  investigation. 

The  separate  identity  of  diphtheria  and  membranous  croup  has  occa- 
sioned much  discussion.  It  has  been  held,  on  the  one  hand,  that  the  two 
diseases  are  etiologically  and  anatomically  identical,  however  much  their 
clinical  aspects  may  differ ;  and,  on  the  other  hand,  that  throughout  they 
are  two  very  distinct  diseases. 

If  the  Klebs-L()ffler  bacillus  be  accepted  as  a  sine  qua  nan  in  the  etiology 
of  diphtheria,  then  croup  must  necessarily  be  separated  from  it.  As  a  matter 
of  fact,  the  anatomical  appearance  of  the  membrane  in  both  diseases  is  identi- 
cal, excepting  only  the  absence  of  the  Klebs-Loffler  bacillus,  the  two  lesions 
differing  only  in  degree,  while  the  clinical  histories  are  very  different. 

In  croup  the  inflammation  begins  in  the  larynx,  whereas  in  diphtheria  it 
rarely  commences  there,  but  passes  by  extension  from  the  pharynx.  In  croup 
the  necrotic  change  is  more  superficial  and  may  be  limited  to  the  epithelium, 


PNoaxo.s/s.  387 

whereas  in  diphtheria  tlie  deeper  layers  of  the  mucous  membrane  are  involved, 
and  even  the  submncosa  may  sometimes  slonjrh.  AHhouoh  the  membranes 
may  appear  alike,  excepting  in  regard  to  the  i)resenee  of  the  Klebs-Loffler 
bacillus,  clinically  the  two  diseases  are  verv  uidike. 

^Membranous  croup  is  a  local  disease;  diphtheria  is  a  general  disease  with 
a  local  inflammation.  Croup  is  not  epidemic  or  contagious,  and  very  rarely 
affects  adults,  as  diphtheria  may.  Albuminuria  does  not  occur,  no  paralytic 
sequelfe  follow,  and  the  lymjihatic  glands  are  less  apt  to  be  enlarged  than  in 
diphtheria.  In  croup  the  inflannnation  begins  suddenly  in  the  larynx,  and 
does  not  readily  tend  to  spread  to  the  trachea  or  oesophagus.  The  invasion  of 
croup  is  apt  to  be  more  sudden  and  severe  than  it  is  in  diphtheria. 

The  sore  throat  occurring  with  scarlatina  is  sometimes  mistaken  for  diph- 
theria, and,  in  fact,  the  latter  disease  may  sometimes  occur  in  conjunction  with 
scarlatina.  In  the  scarlatinal  throat  the  redness  is  much  more  diffuse  than  in 
diphtheria,  and  there  is  the  characteristic  "strawberry  tongue."  In  doubtful 
cases  a  careful  bacteriological  examination  should  be  made,  when  streptococci 
may  be  found,  but  the  Klebs-f^offler  bacillus  will  be  absent. 

In  erysipelas  of  the  throat  the  cervical  glands  are  less  apt  to  be  enlarged, 
and  the  tonoue  is  brown  and  drv,  and  the  mode  of  extension  of  the  two  dis- 
eases  is  very  different. 

Occasionally,  syphilitic  mucous  patches  in  the  pharynx,  with  inflammation 
of  the  fauces,  may  resemble  diphtheritic  inflannnation,  but  the  history  of  the 
case  and  the  absence  of  acute  constitutional  symptoms,  with  the  course  of  the 
disease.  Mill  soon  establish  the  diagnosis. 

In  adults  in  any  doubtfid  case  of  throat  lesion  the  urine  must  be  exam- 
ined. The  sudden  appearance  of  albumin  favors  the  diagnosis  of  diphtheria, 
for  it  does  not  occur  in  simple  tonsillitis  or  pharyngitis.  Moreover,  the  pecu- 
liarities of  the  pseudo-membrane,  its  extension,  and  the  ])rogress  of  the  con- 
stitutional symptoms  will  seldom  fail  to  distinguish  diphtheria  from  the 
former  affections. 

Prognosis. — The  ])rognosis  should  always  be  guarded.  It  varies  in  differ- 
ent epidemics.  It  is  flivorable  in  the  absence  of  extension  of  the  mend)rane 
to  the  throat  or  nose,  in  the  absence  of  albumiiuiria,  and  with  fair  digestion 
and  a  strong  heart-action.  Patients  seen  early  and  properly  treated  stand  a 
very   fair  chance  of  recovery. 

Cases  of  nasal  diphtheria  are  ai)t  to  end  fatally  unless  vigorously  treated. 
It  is  probable  that  this  is  so  because  of  the  great  vascularity  and  abundant 
Ivmphatic  ves>«els  of  tiie  Schneiderian  membrane,  whieh  ic:idily  Mbsorb  sejitic 
material  and  distribute  it  in  the  system.  A  brownish,  watery,  nasal  discharge, 
streaked  with  blood  and  having  an  offensive,  sweetish  odor,  is  a  worse  omen 
than  a  thick  membrane.  Involvement  of  tln>  hard  p:il:i(e  ;uid  in.iuth  to  an 
extreme  deirree  is  worse  than   extension   to  the    n(i>e. 

The  f|nautity  of  the  membrane  formed  does  \uA  alway>  indicate  the  severity 
of  the  disease.  Patients  may  exliii)i(  a  mere  trace  of  it  in  the  fauces  while 
they  are  in  collapse  from   systemic  blood-i)oisoning ;  (.r  the  membrane  may 


388  DIPHTHERIA. 

be  an  eighth  of  an  inch  in  thickness  and  cover  a  wide  area,  and  yet  recovery 
may  take  place.  As  a  general  rule,  however,  a  rapidly-extending,  uncontrol- 
lable inflammation  makes  the  prognosis  very  grave.  The  temperature  affords 
very  little  guidance  in  prognosis.  The  disease  is  the  more  fatal  the  younger 
the  child.  The  worst  cases  occur  while  the  epidemic  is  advancing,  not  when 
it  declines. 

The  prognosis  is  worse  when  scrofula  exists,  and  when  the  diphtheria 
follows  an  attack  of  measles  or  scarlatina  which  has  already  exhausted  the 
child. 

Mortality. — The  death-rate  of  diphtheria  varies  with  different  epidemics. 
It  sometimes  exceeds  40  per  cent,  and  has  even  reached  76  per  cent.  With 
900  cases  recently  treated  in  Strasbourg  the  mortality  was  46.7  per  cent.  In 
New  York  it  averages  above  47  per  cent.,  and  may  reach  55  per  cent.  When 
cases  are  isolated  and  favorably  placed  and  treated  it  is  much  less.  Over  50 
per  cent,  of  the  deaths  from  diphtheria  occur  in  children  under  five  years  of 
age,  and  about  75  per  cent,  occur  among  those  under  ten  years  of  age.  Despite 
every  effort  for  the  control  of  diphtheria,  the  death-rate  has  remained  undi- 
minished  for  many  years,  and  it  often  proves  fatal  to  very  robust  children. 

Treatment. — Prophylaxis. — The  greatest  danger  in  the  spread  of  diph- 
theria is  through  the  agency  of  "  ambulatory  "  cases — i.  e.  cases  in  which  the 
symptoms  are  so  slight  as  not  to  prevent  the  patient  from  going  about,  and 
which  nevertheless  communicate  the  disease  readily  to  other  persons.  A  mild 
case  in  one  individual  may  by  contagion  beget  a  severe  or  malignant  one  in 
another. 

When  diphtheria  is  epidemic  precautionary  measures  should  be  taken 
wherever  children  are  crowded  together  in  school-rooms,  asylums,  or  hospi- 
tal wards ;  strict  personal  and  general  cleanliness  should  be  enforced ;  and  any 
child  having  the  least  indication  of  a  sore  throat  should  be  kept  apart  from 
the  rest.  Cleanliness  of  streets,  yards,  privies,  etc.  is  very  important,  for  the 
disease  thrives  in  filth.  An  abundant  supply  of  pure  water  is  highly  essen- 
tial, and  good  ventilation  of  dwellings  and  school-rooms  should  be  insisted 
upon.  It  is  often  desirable  to  close  the  public  schools  temporarily  to  prevent 
contagion.  Isolation  and  disinfection  are  cardinal  principles  in  regard  to  the 
treatment  of  diphtheria,  no  matter  how  mild  it  may  appear.  Any  infected 
animals  should  at  once  be  killed.  In  the  event  of  a  death  from  di])htheria 
the  body  should  be  wrapped  in  a  sheet  wet  in  1  :  3000  corrosive-sublimate 
solution,  and  placed  immediately  in  a  sealed  casket,  and  the  funeral  sliould 
be  strictly  private,  for  the  disregarding  of  this  precaution  has  been  a  fertile 
source  of  epidemics. 

The  Hygiene  of  the  Sick-room. — The  patient  should  be  placed  in  a  bare 
room,  free  from  superfluous  hangings,  rugs,  or  furniture,  and  kept  very  quiet 
in  bed.  The  temperature  of  the  room  should  not  rise  above  68°  F.  The  air 
should  be  kept  pure  by  free  ventilation.  If  an  adjoining  room  can  be  secured 
in  which  windows  can  be  opened,  it  will  greatly  facilitate  ventilation  without 
exposure  to  draughts.    In  cold  weather  an  open  fire  is  desirable  for  ventilation 


TREA  TMENT.  389 

as  well  as  warmth.  In  wariuer  weather  a  lamp  should  he  kept  constantly 
burning  inside  the  fireplace  in  order  to  make  a  current  up  the  chimney.  The 
bed  should  be  so  placed  that  both  sides  can  be  rcadilv  accessible.  All  discharffes 
from  the  patient  should  be  carefully  disinfected.  Cheese-cloth  rags  should  be 
used  instead  of  handkerchiefs,  and  immediately  burned.  Brushes  used  in  the 
throat  or  nose  should  be  kept  in  corrosive-sublimate  solution,  and  swabs  should 
be  burned  after  a  single  application.  No  one  should  be  admitted  to  the  room 
excepting  the  physician,  nurse,  or  such  members  of  the  family  as  may  be  in 
constant  attendance.  Those  in  charge  of  the  patient  should  be  held  in  strict 
quarantine  from  the  other  occupants  of  the  house.  It  is  advisable  for  the  phy- 
sician on  entering  the  sick-chamber  to  don  a  long  linen  apron  or  a  sheet,  for  in 
examining  the  patient  shreds  of  membrane  arc  sometimes  coughed  up  and  light 
on  the  clothing,  and  the  disease  has  been  carried  to  others  in  this  manner.  In 
making  applications  to  the  throat  which  excite  coughing  one  should  be  particu- 
larly careful  lest  the  membrane  be  expelled  in  the  face,  and  plain  glasses  may 
be  worn  to  save  the  eyes  from  such  danger.  On  leaving  the  room  the  clothing 
should  be  brushed,  and  the  hands  and  beard  should  be  washed  in  corrosive  sub- 
limate, and  it  is  well  to  pass  promptly  into  the  open  air.  Those  in  constant 
attendance  upon  diphtheritic  cases  do  well  to  spray  their  own  nostrils  and 
throats  several  times  a  day  with  weak  corrosive-sublimate  solution  (1  :  10,000) 
or  a  similar  disinfectant. 

When  dij)hthcria  is  epidemic  the  patients  should  not  only  be  isolated  from 
the  healthy,  but  from  each  other,  for  crowding  them  together  in  wards  greatly 
increases  the  virulence  of  the  disease. 

Many  of  the  foregoing  details  may  seem  trivial,  and  they  are  often  over- 
looked, but  experience  with  infection  from  truly  malignant  cases  of  diphtheria 
has  demonstrated  that  they  are  of  the  utmost  importance. 

The  patient  should  be  disturbed  no  more  than  is  necessary  for  the  accom- 
plishment of  treatment. 

Local  applications  in  diphtheria  should  always  be  vigorously  employed,  un- 
less the  patient  is  a  very  young  or  nervous  child  who  is  almost  frightened  into 
convulsions  by  their  use.  As  a  rule,  a  little  tact  and  perseverance  on  the  j)art 
of  the  physician  and  nurse  will  in  time  overcome  any  resistance.  If  the  patient 
be  very  feeble  or  unconscious,  care  must  be  taken  that  no  poisonous  applications 
are  swallowed.  The  pharynx  can  often  be  reached  by  pouring  disinfectants  in 
the  nose — an  operation  which  is  innch  less  alanniiig  to  a  young  infant  llian 
forcibly  opening  the  mouth. 

Local  applications  are  useful— (1)  as  germicides;  {'!)  for  cleansing  pur- 
poses; (3)  to  dissolve  the  false  meml)ran(' ;  (4)  to  allay  irritation.  As  a  rule, 
the  apj)lications  should  be  warm  ami   mild. 

The  most  successful  htcal  treat inciil,  h(.\vcvcr,  is  lh:il  which  is  employed 
with  the  object  of  disinfecting  and  cleansing  uiianected  surfaces,  and  of  (here- 
by making  them  less  lial)le  to  inflainmatioii  niid  to  beget  noxious  products  for 
absori)tion.  Local  treatnicnt  is  of  very  little  avail  as  a  curative  measure  wIkm 
the  lesion  is  once  established.      It  is  well  to  constantly  disinfect  the  nasal  pas- 


390  DIPHTHERIA. 

sages  in  every  case,  to   prevent   possible  extension  of  the  inflammation  in  a 
direction  in  which  it  is  often  overlooked. 

The  common  methods  of  making  the  local  applications  are  by  an  atomizer 
or  spray,  a  nasal  syringe  or  douche,  gargle,  insufflation,  or  by  the  use  of  a 
camel's-hair  brush  or  a  piece  of  absorbent  cotton  on  a  swab.  The  choice  of 
method  will  depend  upon  the  conditions  to  be  met  in  a  given  case.  Gargles 
are  not  very  effectual.  As  a  rule,  the  syringe  is  best  for  nasal  diphtheria,  and 
the  spray  is  most  useful  for  applying  antiseptics  or  solvents  to  the  false  mem- 
brane, while  the  swab  is  of  service  when  single  stronger  applications  are  indi- 
cated or  where  a  piece  of  loosened  membrane  is  to  be  detached.  It  is  some- 
times useful  to  combine  several  methods.  A  small  syringe,  with  a  small  piece 
of  rubber  tubing  slipped  over  the  nozzle,  serves  well  for  cleansing  the  nose. 
The  nurse  should  be  instructed  to  apply  the  stream  horizontally  and  very 
gently.  A  nasal  syringe  has  been  devised  with  a  soft-rubber  top  which  fits 
the  nostril  conveniently.  In  syringing  the  nose  the  head  should  be  held  well 
forward  and  the  child  told  to  breathe  through  the  mouth.  Should  pain  in  the 
ears  be  complained  of  after  the  syringing,  it  must  be  abandoned,  and  the  fluid 
may  be  poured  in  with  a  spoon  or  medicine-dropper. 

If  the  nares  are  entirely  occluded  by  thick  membrane  and  secretion,  they 
may  be  cleansed  by  a  probe  carrying  cotton  dipped  in  a  little  50  per  cent,  solu- 
tion of  carbolic  acid.  This  strong  solution  should  only  be  used  upon  the  false 
membrane.  Afterward  the  nasal  cavities  may  be  kept  clean  by  a  saturated 
solution  of  boric  acid,  or  one  of  ten  minims  of  carbolic  acid  to  the  ounce  of 
lime-water. 

It  is  ob\-iously  unwise  and  unnecessary  to  attempt  the  use  of  a  laryngo- 
scope to  facilitate  examination.  All  applications  to  the  nasal  mucous  mem- 
brane should  be  very  mild  and  warm.  Frequently  warm  local  applications  to 
the  throat  give  more  relief  than  cold,  but  many  patients  crave  the  cold  and 
enjoy  cold  water,  cracked  ice,  simple  water-ices,  ice-cream,  etc. 

In  order  to  keep  down  a  rapidly-spreading  inflammation  and  an  accumida- 
<  ion  of  false  membrane,  which  would  be  inevitably  fatal,  it  is  absolutely  neces- 
.sary  to  adopt  measiu-es  which  at  the  time  may  appear  severe.  Thus  in  very 
bad  cases  local  applications  must  be  made  continuously  every  half  hour  by  day 
and  every  hour  by  night,  and  exceptionally  even  oftener,  although  they  inter- 
fere with  sleep.  Sometimes  patients  become  so  fatigued  that  they  will  drop 
asleep  while  the  application  is  being  made,  or  they  will  bitterly  complain  of 
being  so  frequently  disturbed.  Experience  teaches,  however,  that  vigorous 
local  treatment  is  the  only  means  of  preventing  the  extension  of  inflammation 
to  the  larynx  and  nares,  and  many  lives  may  be  saved  by  firmness  in  this 
respect.  When  children  once  pass  into  a  septic  coma  it  is  wellnigh  impossible 
to  arouse  them.  It  taxes  the  physician's  best  judgment  to  avoid  the  danger 
of  exhausting  the  patient's  strength  by  too  energetic  local  treatment,  and  the 
even  greater  dangers  of  sepsis  and  occlusion  of  the  air-passages  by  rapidly- 
spreading  false  membrane. 

If  there  be  an  accumulation  of  false  membrane  already  formed  in  the  larynx, 


THE  A  TMENT.  391 

an  emetic  of  tiirpeth  mineral  will  sometimes  enable  the  child  to  discharge  a 
considerable  portion  of  it,  with  immediate  relief  to  the  accom  pan  vino-  dys- 
pnoea.. 

Much  tact  is  required  in  the  management  of  young  infants,  who  are  apt  to 
be  greatly  alarmed  by  attempts  at  local  treatment.  In  such  instances  firmness 
and  gentleness  will  often  overcome  objection.  It  must  be  remembered  that 
hard  crying  with  deep  inspiration  may  loosen  a  bit  of  false  membrane,  which 
is  carried  into  the  larynx  or  trachea  to  set  up  a  fresh  infection  with  fatal 
result.     Often,  however,  the  infants  are  too  ill  to  cry  violently. 

Any  application  should  be  abandoned  which  tends  to  derange  the  stomach. 
Very  young  children,  as  a  rule,  will  not  tolerate  the  spray,  and  they  are 
unable  to  gargle.  In  such  cases  the  tincture  of  the  chloride  of  iron  may  be 
given  in  doses  of  five,  ten,  or  fifteen  minims  in  glycerin  and  peppermint-water 
every  half  hour.  A  child  a  year  old  will  take  a  drachm  or  more  in  the 
course  of  twenty-four  hours  with  benefit.  Swallowing  the  frequently  re- 
peated doses  serves  the  purpose  of  local  application  fairly  well,  for  a  certain 
amount  adheres  to  the  diseased  mucous  surface.  A  useful  formula  for  a 
young  child  is — 

I^.    Tinct.  ferri  chloridi,  f^jss  ; 

Glycerin i  pur.,  f^ss  ; 

Aquae  menth.  piper.,  f.SJ  ; 

Aquffi,  q.  s.  ad  f^iv. — M. 
Sig.  Give  fsj  every  half  hour. 

The  iron  acts  beneficially  by  constricting  the  blood-vessels,  and  possibly  also 
the  lymphatic  vessels,  and  by  diminishing  absorption  of  septic  products.  It 
is  also  antiseptic,  reduces  local  hypenemia  and  swelling,  and  toughens  the 
membrane  already  formed. 

The  chlorate  of  })otassium  is  sometimes  given  with  iron,  but  it  is  a])t  to 
impair  digestion,  and,  in  large  doses,  may  excite  hsematuria.  Since  the  kidneys 
are  often  more  or  less  inflamed,  this  remedy  should  be  used  with  great  caution. 

The  pseudo-membrane  should  never  be  torn  off  or  rudely  removed,  so  as 
to  expose  a  fresh  bleeding  surface  to  reinoeulation  and  extension  of  tiie 
inflammation,  but  a  good  deal  of  loosened  membrane  may  carefully  be  dis- 
lodged by  a  bit  of  dry  flannel  fjistened  to  a  strip  of  wood  and  used  as  a 
probe.  After  the  pseudo- membrane  has  been  coagulated  and  hardened  by 
topical  apidications  it  is  often  freer,  and  can  be  more  readily  removed,  but 
unless  it  comes  off  very  easily  it  should  be  let  alone.  Loosened  membrane, 
unless  it  be  removed  or  coughed  out,  is  liable  to  be  swallowed  or  inhaled. 

If  it  becomes  necessary  to  remove  loosened  false  membrane  or  make  a  local 
application,  a  kieking  child  may  be  rolled  in  a  blanket  and  held  up  by  the 
nurse  while  a  swab  is  used.  A  teaspoon  or  a  medicine-droj)per  may  be 
employed  to  pour  fluid  into  the  nostrils,  instead  of  the  rubber  tubing  and 
syringe. 


392  DIPHTHERIA. 

A  great  number  of  local  applications  are  made  with  a  view  of  hardening 
and  freeing  the  pseudo-membrane  and  checking  its  extension.  Such  are  the 
following  solutions :  tincture  of  the  chloride  of  iron,  10  per  cent.,  in  glycerin 
and  watci-  (applied  with  a  brush) ;  common  salt,  f  per  cent. ;  salicylic  acid, 
\  per  cent.  ;  creolin,  1  per  cent. ;  creasote ;  resorcin,  10  per  cent.,  in  gly- 
cerin ;  menthol ;  carbolic  acid,  1  per  cent. ;  boric  acid,  saturated  aqueous  solu- 
tion ;  corrosive  sublimate,  1  :  2000  or  3000;  potassium  permanganate;  sodium 
hypophosphite. 

Applications  of  strong  solutions  of  silver  nitrate,  hydrochloric  acid,  or  car- 
bolic acid  to  the  diseased  mucous  surface  have  been  extensively  tried,  but  such 
harsh  measures  are  now  universally  condemned ;  for,  if  local  applications  are 
made  too  strong,  they  weaken  the  neighboring  healthy  mucous. membrane  and 
render  it  liable  to  infection.  Nothing  caustic  or  irritating  should  ever  be  ap- 
plied, for,  although  such  substances  may  temporarily  destroy  the  membrane, 
it  soon  re-forms  over  a  larger  area,  with  increased  inflammation  and  tumefac- 
tion, and  deep  sloughs  may  follow. 

Vapors  of  turpentine,  eucalyptus,  carbolic  acid,  etc.  are  sometimes  em- 
ployed about  the  room  and  for  the  patient  to  inhale,  but  they  are  of  doubtful 
efficacy.  Considerable  relief  is  often  obtained  by  the  use  of  steam  generated 
in  a  "  croup  kettle"  or, in  an  ordinary  kettle,  the  steam  being  directed  under  a 
sheet  arranged  as  a  hood  over  the  patient's  head.  Lime-water  or  eucalyptol 
is  sometimes  added  to  the  vapor.  The  steam  favors  suppuration,  and  the 
false  membrane  is  loosened  thereby.  Such  inhalations  are  especially  valuable 
in  the  laryngeal  form  of  the  disease. 

The  continued  use  of  a  corrosive-sublimate  spray  may  over-stimulate 
the  membrane  and  produce  too  much  mucous  secretion.  Should  this  be  the 
case,  it  must  be  employed  less  frequently  and  in  alternation  with  some  less 
irritating  application. 

Single  applications  of  corrosive  sublimate  on  a  swab  may  be  used  in  the 
strength  of  1  :  1000,  but  the  spray  should  be  diluted  to  1  :  2000  or  1  :  3000 
and  used  with  care.  For  young  children  it  should  be  still  weaker — 1  :  5000 
or  1  :  10,000.  A  little  common  salt  is  often  added.  Jacobi  recommends  the 
use  of  a  s])ray  containing  a  grain  of  corrosive  sublimate  to  the  pint,  with  a 
drachm  of  table  salt  added. 

In  young  infants  there  is  some  risk  in  the  free  local  use  of  corrosive 
sublimate,  because  it  is  difficult  to  estimate  how  much  is  being  swallowed  and 
absorbed.  In  such  cases  salicylic  acid,  1  :  1500,  makes  a  less  injurious  wash 
for  the  nasal  cavities.  A  saturated  solution  of  boric  acid  in  water  is  also 
serviceable  as  a  douche ;  as  is  common  salt,  one  drachm  to  a  pint  of  warm 
water. 

For  solvents  of  the  mucous  membrane  preparations  of  ])ancreatin  or 
papayotin,  1  :  20  in  water,  are  used  witli  benefit  as  sprays  or  topical  applica- 
tions. It  is  somewhat  doubtful  whether  these  substances  really  dissolve  the 
false  membrane  to  any  great  extent,  but  they  do  seem  to  check  its  extension 


TREATMENT.  393 

and  to  cleanse  the  surface.     A  good  spray  for  use  when  corrosive  sublimate 
cannot  be  safely  employed  consists  of — 

I^.  Acidi  carbolici,  lU^'j  ; 

Liquor  calcis,  fsiv. — M. 

Sig.  Apply  with  an  atomizer  every  half  hour  or  hour. 

Recently  hydrogen  peroxide  has  been  extensively  tried,  with  excellent 
results,  as  a  spray  in  a  5  per  cent,  or  10  per  cent,  aqueous  or  glycerin  solu- 
tion of  the  1 5-volume-strength  solution.  This  does  not  dissolve  the  mem- 
brane, but  it  acts  as  a  cleansing  and  disinfecting  agent.  It  does  not  corrode, 
nor  does  it  injure,  sound  tissue  when  properly  diluted. 

liocal  applications  to  the  outside  of  the  throat  are  useless  to  relieve  the 
inflammation  of  the  mucous  surfaces.  If  the  cervical  glands  are  swollen  and 
painful,  thev  may  be  relieved  by  application  of  belladonna  liniment  or  iodo- 
form ointment,  and  an  ice-bag.  Should  they  sn})purate,  which  is  unusual, 
they  must  be  actively  poulticed  and  then  incised. 

When  the  eye  becomes  inflamed  the  opposite  one  should  be  protected  from 
infection  by  a  pad  and  adhesive  plaster.  The  constant  application  of  cold  to 
the  lid  and  ihe  use  of  a  saturated  solution  of  boric  acid  are  the  best  remedial 
agents. 

Intubation  and  Tracheotomy. — Intubation  of  the  larynx  is  a  method 
devised  by  O'Dwyer  of  New  York.  It  consists  in  the  operation  of  insert- 
ing a  small  gold-plated  tube  between  the  vocal  cords  and  leaving  it  there,  so 
that  air  can  freely  pass  in  and  out,  tiie  channel  previously  blocked  by  false 
membrane  being  kept  open  by  the  tube.  The  tube  is  carefully  adapted  to  be 
held  between  the  vocal  cords,  and  various  sizes  are  made  to  fit  any  larynx. 
The  tube  is  passed  into  the  larynx  by  an  ingenious  holder,  which  releases  it 
when  in  position,  and  an  instrument  is  also  employed  for  its  removal  for  the 
purpose  of  cleansing  it,  extracting  plugs  of  membrane,  etc.  The  holder  is 
grasped  in  one  hand,  while  the  index  finger  of  the  other  hand  serves  as  a 
guide  for  the  tube,  a  gag  being  usually  necessary  to  protect  the  finger.  As  a 
precaution  against  the  tube  being  coughed  up  and  swallowed  a  thread  is  tied 
to  it,  which  may  be  brought  out  of  the  mouth  and  fastened. 

The  practice  of  intubation  has  many  and  decided  advantages  over  trache- 
otomy. It  does  away  with  the  necessity  for  tracheotomy,  a  surgical  operation 
which  the  patient's  family  usually  abhor,  if  they  do  not  actually  forbid  it.  It 
is  speedily  performed  by  one  skiHed  in  the  use  of  the  instrument,  and  it  can 
be  done  at  a  moment's  notice.  The  tube  can  be  readily  cleansed  and  rein- 
serted. The  relief  afforded  is  as  instant  as  that  of  tracheotomy,  and  the  ope- 
ration of  inserting  the  tube  is  more  quickly  performed  and  it  may  be  done 
earlier.  The  tube  irritates  the  throat  no  more  llian  a  tracheotomy-tube.  In 
case  of  recovery  the  tube  is  more  promptly  removed  than  a  tracheotomy-tube 
— in  five  or  six  instead  often  days — an<l  there  is  no  wound  k>ft  to  close. 

Tiic  disadvantages  which  it  may  have  are— first,  that  it  is  said  to  push  the 


394  DIPJITITERIA. 

false  membrane  from  the  larynx  down  into  the  trachea,  whereas  the  trache- 
otomy-tube passes  in  below  the  larynx  ;  second,  it  is  sometimes  coughed  out 
by  the  child,  who  suffocates  before  it  can  be  replaced ;  third,  it  may  be  diffi- 
cult for  the  child  to  swallow  without  drawing  food  into  the  trachea.  This 
trouble  is  chiefly  confined  to  fluids  and  not  to  semifluid  or  solid  food.  With 
proper  precautions,  however,  these  shortcomings  can  be  reduced  to  a  minimum. 

If  necessary,  rectal  alimentation  may  be  temporarily  resorted  to,  or  a  small 
oesophageal  tube  may  be  passed,  though  the  latter  method  is  apt  to  be  too  irri- 
tating. Many  children  can  learn  to  swallow  well  with  a  little  practice  after 
the  tube  is  inserted. 

The  operation  of  tracheotomy  cannot  be  here  detailed,  as  it  belongs  to 
surgery. 

After  either  intubation  or  tracheotomy  the  tube  should  be  watched  con- 
stantly with  great  care,  lest  it  become  occluded  with  mucus  or  pseudo-mem- 
brane and  cause  suffocation.  If  a  tracheotomy-tube  be  employed,  it  should  be 
covered  by  a  compress  of  cheese-cloth  or  other  light  material  soaked  in  a 
warm  antiseptic  solution.  The  tube  should  be  fitted  with  a  proper  attachment, 
so  that  a  piece  of  rubber  tubing  can  be  fastened  over  it,  and  with  the  aid  of  a 
hard-rubber  syringe  mucus  may  be  sucked  out  of  the  tube  by  the  nurse.  A 
soft-rubber  catheter  should  also  be  in  readiness  to  pass  through  an  obstructed 
tube  when  necessary  to  clean  the  passage.  Jacobi  recommends  a  long  feather 
for  the  same  purpose,  as  bits  of  membrane  and  mucus  are  apt  to  adhere  to  it. 

Symptoms  which  make  either  tracheotomy  or  intubation  urgent  are  quick- 
ened, stertorous  respiration,  unremitting  dyspnoea,  cyanosis,  increased  restless- 
ness and  anxiety  of  the  patient.  Aphonia  with  difficulty  in  both  inspiration 
and  expiration  indicates  the  presence  of  false  membrane  in  the  larynx  (Jacobi). 
There  is  also  marked  falling  in  of  the  suprasternal  and  epigastric  regions 
accompanying  the  inspiratory  effx)rts. 

If  the  lungs  are  already  involved  or  if  the  pseudo-membrane  has  passed 
down  beyond  the  larynx,  opening  the  trachea  is  of  no  avail.  Either  operation 
may  be  performed  when  there  is  no  real  hope  of  recovery,  simply  to  save  the 
patient  from  a  very  distressing  death  from  suffocation. 

Unless  immediate  relief  follows  tracheotomy  or  intubation  when  done 
early,  there  is  strong  probability  that  the  trachea  and  bronchi  are  already 
invaded  by  the  inflammation. 

A  statistical  comparison  between  the  mortality  of  tracheotomized  and 
intubation  oases  is  of  little  value,  for  tracheotomy  is  usually  left  as  a  last 
resort,  and  both  methods  are  only  employed  in  laryngeal  diphtheria,  which  is 
exceedingly  fatal  in  young  children.  Both  methods  serve  to  prevent  the  child's 
dying  of  suffocation,  and  a  small  percentage  are  actually  saved.  In  1890 
statistics  from  various  sources  were  collected  of  2368  cases  in  which  intuba- 
tion had  been  practised,  with  a  recovery  of  27.3  per  cent.  The  mortality  from 
tracheotomy,  however,  is  quite  as  high.  Fully  95  per  cent,  of  the  cases  of 
laryngeal  diphtheria  in  children  and  infants  die  unless  relieved  by  intubation 
or  tracheotomy. 


TREA  TMEXT.  395 

Treatment  of  Special  Symptoms. — Paralyses  of  the  pharvngeal  muscles, 
soft  palate,  or  tongue  may  interfere  with  deglutition  and  articulation. 
Attempts  to  swallow  fluid  result  in  its  regurgitation  through  the  nose.  Such 
patients  must  be  fed  by  an  oesophageal  tube.  For  the  paralyses  strychnine 
and  other  tonics,  such  as  quinine  and  iron,  are  of  service.  Massage  or  a  mild 
electric  current,  galvanic  or  faradic,  may  be  used,  but  the  latter  is  of  doubt- 
ful efficacy,  for  most  cases  recover  of  themselves.  If  there  be  cardiac  paraly- 
sis, absolute  quiet  in  a  recumbent  position  must  be  enjoined,  and  strychnine  and 
brandy  must  be  given  hypodcrmically,  with  ammonia  or  camphor  internally. 

If  the  temperature  be  high,  sponge-bathing  of  the  surface  with  cold  water 
and  alcohol  in  equal  parts  is  useful.  Dyspnoea  is  sometimes  relieved  by 
placing  the  child  in  a  warm  bath  for  a  few  minutes. 

Internal  Remedies. — The  internal  use  of  corrosive  sublimate  in  diphtheria 
has  greatly  gained  in  favor  during  the  past  few  years,  and  it  is  now  accepted 
as  the  best  remedy.  It  seems  to  be  particularly  well  tolerated  by  children 
having  diphtheria,  and  they  are  soon  able  to  take  large  doses,  gradually 
increased.  As  much  as  one-fortieth  of  a  grain  may  be  given  every  two  hours 
to  a  child  three  or  five  years  old.  The  rule  is  to  administer  small,  frequent 
doses,  carefully  watching  the  effect,  and  the  drug  must  be  diluted  in  water  or 
milk  to  1  :  5000.  Jacobi  states  that  a  child  a  year  old  may  take  as  much  as 
half  a  grain  in  the  twenty-four  hours,  divided  into  small  doses.  Should 
stomatitis  or  any  indication  of  intestinal  derangement,  such  as  irritable 
diarrhoea,  occur,  the  drug  must  of  course  be  stopped  at  once ;  and  in  every 
case  its  effects  should  be  most  carefully  observed,  and  the  doses  should  be 
very  small  at  first  until  it  is  ascertained  that  they  are  well  tolerated. 

The  method  of  using  the  tincture  of  the  chloride  of  iron  has  been  detailed 
above,  for  the  benefit  derived  from  it  seems  quite  as  great  locally  as  in  any 
other  way.  It  is  commonly  combined  with  glycerin,  diluted  in  water,  and  is 
given  in  large,  frequent  doses. 

Stimulation  and  cardiac  tonics  should  be  employed  early  in  the  disease,  and 
constantly,  for  there  is  much  more  hope  of  preventing  heart-failure  than  of 
counteracting  it  when  present.  Digitalis,  strophanthus,  cafieinc,  ammonium 
carbonate,  strychnine,  (;amj)hor,  and  alcohol  are  the  remedies  most  favored. 
The  citrate  or  sodo-benzoate  of  caffeine,  when  the  urine  is  scanty,  is  useful 
for  its  diuretic  effect. 

Alcohol  is  demanded  early  in  nearly  all  cases.  In  those  which  commence 
with  severity  it  should  be  given  at  once  to  prevent  cardiac  fiiilurc,  in  the  form 
of  diluted  whiskey  or  brandy.  Infants  tolerate  brandy  well.  An  infant  may 
be  given  twenty  dro])s  of  brandy,  or  a  child  of  four  or  five  y(^nrs  from  one  to 
two  drachms,  every  hour  or  two,  or  oftencr  if  very  firble.  When  swalU)wing 
is  difficult  or  if  the  stomach  be  enfeebled,  stinndants  must  be  given  by  the 
rectum.  Half  an  ounce  <jf  brandy  in  a  little  milk  may  be  administered  by 
this  means  every  two  or  three  hours  to  a  child  of  four  or  fiv(^  years. 

The  diet  should  l)e  light  and  nutritious.  During  the  active  stage  of  the 
disease,  while  there  is  fever  and  if  any  diniculty  in  deglutition  exist,  the  food 


396  DirHTHERIA. 

must  be  fluid,  or  semi-solid  if  more  easily  swallowed,  and  should  consist  of 
thick  broths,  beef  tea,  egg-albumin,  egg-nogg,  milk,  milk-punch,  etc.  Ice 
cream  and  wine-jelly  may  be  given.  Rice  and  gruels  are  also  serviceable. 
During  convalescence  patients  are  anaemic  and  require  iron  and  the  bitter 
tonics.  Great  care  should  be  exercised  to  prevent  sudden  exertion  until  the 
heart  is  restored  to  its  normal  strength. 

After  recovery  the  patient  must  be  sponged  with  a  disinfectant,  and  must 
have  the  hair  thoroughly  shampooed.  All  clothing  worn  in  the  sick-room 
should  be  disinfected  by  steam  or  otherwise.  The  bed-linen  and  under-cloth- 
ing; must  be  boiled  and  soaked  for  five  hours  in  a  1  :  2000  solution  of  corrosive 
sublimate  or  for  twenty-four  hours  in  a  2  per  cent,  solution  of  carbolic  acid. 
It  is  customary  for  health-boards  to  burn  sulphur  in  the  bed-room,  using  three 
pounds  to  every  thousand  cubic  feet  of  air-space,  then  airing  the  room  thor- 
oughly for  a  day  or  two.  The  sulphur  has  been  shown  to  be  of  somewhat 
doubtful  efficacy  (Prudden),  and  it  has  little  effect  unless  abundant  moisture 
or  steam  be  present ;  and  this  is  seldom  practicable  in  a  private  dwelling. 

The  room  should  be  thoroughly  washed  and  scrubbed  with  corrosive  subli- 
mate, 1  :  1000,  or  carbolic-acid  solutions,  and  the  walls  should  be  rubbed  down 
with  bread-crumbs.  If  the  case  has  been  of  malignant  type,  it  is  better  to 
repaper  the  walls  and  repaint  the  ceiling  and  woodwork  before  any  one,  espe- 
cially a  child,  occupies  the  room.  Furniture  must  be  rubbed  with  cloths  wet 
in  a  5  per  cent,  solution  of  carbolic  acid. 

The  infectivity  of  a  patient  may  outlast  the  local  symptoms,  and  it  is  a  safe 
rule  to  keep  children  away  from  school  for  at  least  a  month  after  the  disappear- 
ance of  all  local  symptoms.  Diphtheritic  paralysis  is  known  to  occur  in  ani- 
mals and  man  some-tirae  after  all  local  symptoms  have  gone,  showing  that  the 
disappearance  of  the  membrane  must  not  be  invariably  taken  as  a  criterion  of 
complete  recovery. 


ERYSIPELAS. 

By  W.  GILMAN   THOMPSON. 


Definition. — Erysipelas  is  an  infective  disease,  caused  by  a  specific  micro- 
coccus and  characterized  by  liigli  fever,  an  intense  local  inflammation  of  the 
skin  and  adjacent  mucous  membranes,  with  a  tendency  to  rapid  extension  and 
to  become  contagious,  especially  in  the  presence  of  wounds. 

Synonyms. — St.  Anthony's  fire ;  firysipele  (Fr.) ;  Erysipel,  Rose,  Roth- 
lauf(Ger.). 

Etiology. — Erysipelas  is  divided  clinically  into  two  forms:  1.  Idiopathic 
or  "  medical "  erysipelas,  involving  chiefly  the  face  and  the  head  ;  2.  Trau- 
matic, originating  at  the  site  of  a  wound  anywhere  upon  the  surface  of  the 
body.  For  the  peculiar  features  of  the  latter  the  reader  is  referred  to  works 
upon  sifrgery. 

These  two  varieties  are  now  generally  admitted  to  be  due  to  a  common 
cause — namely,  the  presence  of  a  specific  virus,  a  micrococcus,  which  enters 
the  body,  develops  an  intense  local  inflammation  in  the  integument  around 
the  point  of  entry,  and  forms  poisonous  products,  called  toxines  or  ptomaines, 
which  pass  into  the  systemic  circulation  and  excite  febrile  and  other  constitu- 
tional symptoms.  The  micrococcus,  Streptococcus  en/sipelosiis,  has  been 
described  by  Fehleisen  and  Ziegler.  It  is  always  obtainable  from  the 
inflamed  tissues.  It  presents  a  chain-like  form,  gives  characteristic  gelatin 
cultures,  and  when  inoculated  in  rabbits  and  in  man  develops  true  erysipelas. 
It  has  been  argued  that  in  idiopathic  erysipelas  the  virus  may  gain  access  to 
the  body  otherwise  than  by  inoculation,  because  (a)  Ihe  constitutional  symp- 
toms occasionally  precede  the  local  manifestations,  and  (/;)  a  cutaneous  abra- 
sion is  not  always  discovered.  On  the  other  hand,  it  is  true  that  careful 
search  usually  shows  that  the  inflammation  has  commenced  at  the  site  of  a 
slight  abrasion,  cither  at  the  angle  of  tlie  moutli  or  eye,  or  at  the  septum  or 
ala  of  the  nose,  or  at  a  fissure  behind  the  ear,  or  at  the  auditory  meatus,  or 
sometimes  on  the  mucous  membrane  adjoining  a  carious  tooth  or  where  an 
oc7X'matous  papule  has  been  scratched  away.  In  other  cases,  where  such  abra- 
sion first  admitted  the  virus,  the  local  swelling  may  obscure  the  point  of  entry, 
or  the  abrasion  has  healed  before  the  symptoms  are  observed.  Moreover,  it 
has  been  sufrtrestcd  that  the  local  inflammation  may  really  be  coexistent  with 
the  earliest  constitutional  symptoms,  but  the  products  of  the  inflammation  are 
removed  at  first  by  the  blood  and  lymphatic  capillaries  as  fast  as  they  are 
fi)rmed,  only  giving  rise  to  local  signs  when  they  become  excessive.  Hebra 
and  those  of  his  school  have  held  that  erysipelas  is  a  local   disease,  and  that 

397 


398  ERYSIPELAS. 

all  the  symptoms  are  referable  to  the  intense  dermatitis.  The  majority  of 
observers,  however,  class  erysipelas  as  a  general  or  constitutional  disease  hav- 
ing some  points  of  resemblance  to  specific  fevers.  In  infants  the  disease  often 
commences  at  the  nmbilicus,  genitalia,  or  the  site  of  vaccination.  In  puer- 
peral women  it  invades  the  genitalia,  spreads  down  the  legs,  and  involves  the 
uterus  in  septic  inflammation,  which  attacks  the  extensively  eroded  surface. 
Certain  persons  possess  a  constitutional  predisposition  to  the  disease  and  have 
repeated  attacks. 

Age,  season  of  the  year,  and  climate  do  not  particularly  influence  the  sus- 
ce])til)ilitv  to  the  disease,  nor  does  sex,  apart  from  the  puerperal  state  of  women, 
in  which  condition  it  is  especially  virulent  and  infectious.  Though  not  neces- 
sarilv  originating  through  such  conditions,  the  extension  of  erysipelas  is  greatly 
favored  by  bad  hygienic  surroundings,  filth,  and  overcrowding.  It  has  often 
existed  for  months  in  a  crowded  district  or  a  hospital  ward,  and  it  does  not 
always  spread  far  even  under  concentration.  The  traumatic  variety  is  more 
apt  to  be  transmitted  to  puerperal  patients  than  the  idiopathic. 

Morbid  Anatomy. — There  is  at  first  hypersemia  and  intense  redness  of  the 
skin,  followed  by  an  infiltration  of  lymph  and  corpuscles  into  the  cutis  and 
subcutaneous  connective  tissue.  The  cells  are  round,  granular,  and  pccur  in 
scattered  form  or  in  aggregations.  The  inflammation  may  be  slight,  amount- 
ing only  to  simple  erythema,  or  much  more  severe,  involving  the  subcutaneous 
fat.  When  the  skin  is  loose  there  may  be  extensive  oedema.  The  cellular 
elements  of  the  rete  mucosum  and  the  derma  are  softened  and  swollen  with 
serous  exndate.  Vesication  frequently  occurs.  Chains  of  micrococci  are 
found  in  the  rete  Malpighii  and  in  the  lymph-spaces.  The  capillaries  and 
lym})h-vessels  contain  an  excess  of  corpuscles.  The  inflammatory  process 
may  go  on  to  the  formation  of  pus,  which  is  commonly  diff'use,  but  some- 
times results  in  abscesses  or  gangrene.  The  pus-cells  exhibit  more  or  less 
fatty  degeneration.  Congeries  of  micrococci  are  found  in  the  lymph-spaces  and 
vessels,  around  which  there  is  more  or  less  necrosis.  When  recovery  begins, 
the  serum  is  quickly  absorbed,  the  skin  becomes  flaccid  or  shrivelled  and  pale, 
the  leucocytes  disappear  rapidly,  and  the  granular  debris  in  the  superficial 
layers  of  the  cutis  is  soon  absorbed.  There  are  no  typical  visceral  lesions. 
If  the  fever  has  been  high,  there  may  be  local  congestion  hypersemia,  or 
parenchyniatous  degeneration  of  viscera — such  lesions  as  are  incident  to  the 
fever  or  blood-poisoning.  The  blood  becomes  thin,  dark,  and  coagulates 
poorly.  There  may  be  acute  oedema  of  the  brain.  In  mild  cases  the  inflam- 
mation of  the  skin  disappears  so  completely  after  death  that  it  may  be  impos- 
sible to  detect  it. 

Symptomatolog-y. — The  symptoms  are  both  local  and  constitutional. 

The  local  synijjfoias  are  typical.  The  skin  surrounding  an  abrasion  or  fis- 
sure becomes  raj^idly  hyperseraic,  red,  swollen,  tense,  smooth,  and  shiny.  It 
feels  hot  to-the  touch,  and  the  patient  comj^lains  of  burning  pain  or  itching. 
The  margins  of  the  inflamed  patch  are  irregular,  but  distinct,  and  appear  ele- 
vated both  to  touch  and  sight,  and  form  an  abrupt  contrast  with  the  normal 


SYMPTOMATOLOGY.  399 

skin  beyond.  Such  an  inflamed  patch  extends  rapidly,  until  within  a  day  or 
two  it  involves  nearly  all  of  the  face  and  in  some  cases  the  scalp,  even  reach- 
ing down  to  the  neck  and  shoulders.  The  maximum  inflammation  is  usually 
attained  by  the  third  day. 

In  very  mild  cases  the  inflammation  does  not  progress  beyond  a  simple  ery- 
thema, and  only  a  small  part  of  the  face  may  be  affected.  The  crimson  color 
at  first  fades  momentarily  under  pressure.  In  more  severe  cases  the  inflam- 
mation extends  by  advancing  the  elevated  periphery  or  by  radiating  tedema- 
tons  lines  which  pass  into  the  normal  skin.  Rarely,  isolated  patches,  commen- 
cing as  round  elevated  spots  near  the  primary  inflammation,  coalesce  with  it. 
The  raised  spot  becomes  more  and  more  oedematous,  especially  where  the 
intecrument  is  loose.  The  evelids  are  so  swollen  as  to  obscure  vision,  and  the 
face  becomes  unrecognizable.  Small  vesicles  and  blebs  form  on  the  surface 
and  coalesce  to  form  large  bullae,  filled  with  serum,  which  is  at  first  clear,  but 
may  become  purulent.  This  serum  is  capable  of  reproducing  the  disease  when 
inoculated  in  man  or  animals.  At  this  stage  recovery  may  occur.  The  color 
of  the  skin  grows  more  natural,  inflammation  subsides,  the  oedema  slowly  dis- 
appears, the  blebs  are  absorbed,  rupture,  or  dry  to  crusts,  and  after  five  or  six 
days  of  inflammation  the  skin  undergoes  thorough  desquamation  and  becomes 
quite  normal. 

In  worse  cases  the  swollen  skin  becomes  soft  and  boggy,  pits  on  pressure, 
and  the  surface  is  more  or  less  livid,  bullae  may  become  sanguinolent,  and 
diffuse  subcutaneous  sloughs  and  superficial  gangrene  appear  or  circumscribed 
abscesses  form.  The  spread  of  the  inflammation  is  somewhat  affected  by  the 
character  of  the  skin  :  it  often  stops  short  at  a  deep  fold  like  the  naso-labial  or 
at  the  line  of  the  hairy  scalp,  and  it  often  is  arrested  at  the  chin.  If  lymphatic 
glands  are  near,  lines  of  hypersemia  may  be  seen  extending  toward  them  from 
the  inflamed  area. 

When  the  disease  affects  the  face  and  head  the  adjacent  mucous  membranes 
are  involved ;  the  li])s  and  gums  are  swollen  and  red  ;  the  nares  and  conjunc- 
tivae are  covered  Avith  mucous  secretions,  forming  dry  crusts ;  the  tongue  is  dry 
and  fissured  or  swollen  ;  and  the  pharynx  congested.  Occasionally  the  inflam- 
mation spreads  rapidly  over  the  entire  body  (erysipelas  migrans,  "erratic" 
erysipelas),  producing  enormous  swelling  of  the  extremities.  In  such  cases 
the  skin  presents  simultaneously  the  various  stages  of  the  inflammation.  The 
cervical  glands  often  become  painful  and  swollen. 

Constitutional  Sipnptom.s. — The  c<jnstitutional  syn)ptoms  may  precede  the 
dermatitis  l)y  a  few  days  or  hours,  or  they  are  coincident  with  it.  They  are 
the  symptoms  common  to  the  febrile  state.  Tin  re  is  usually  a  sudden  onset 
with  rigors  or  a  chill,  followed  by  a  sharp  rise  of  temperature  to  104°  or  105° 
F.,  accompanied  by  prostration,  nausea,  and  jierhaps  vomiting,  constij)ation, 
and  lieadache.  In  mild  cases  there  may  be  so  little  malaise  that  the  first  thing 
noticed  is  the  local  inflammation.  Sometimes  the  patient  complains  of  a  sore 
throat.  The  fever  is  usually  remittent,  but  is  irregular,  and  the  temj)eraturc 
mav  be  lower  in  the  cvciiimr  than  in  the   iiioiiiiiig.      It  tends   to  remain  high 


400  ERYSIPELAS. 

for  several  clays.  Occasionally  the  temperature  drops  to  normal,  and  soon 
rises  again  to  104°  or  105°  F.  Remissions  in  the  fever  may  be  accompanied  by 
sweatino-.  The  fever  and  other  constitutional  symptoms  advance  or  abate  with 
the  local  inflammation.  If  the  latter  extends  or  increases  in  intensity,  the 
pulse  becomes  rapid  and  feeble,  possibly  intermittent ;  the  tongue  is  dry  and 
brown;  the  temperature  continues  high,  and  may  reach  106.5°  or  107°  F; 
the  urine  is  scanty  and  moderate,  albuminuria  ensues,  and  the  patient  rapidly 
passes  into  a  typhoid  condition  with  delirium,  which  may  become  maniacal; 
subsultus,  involuntary  evacuations,  often  with  diarrhoea  and  extreme  prostra- 
tion, with  finally  coma  and  death.  Delirium  often  occurs  without  the  typical 
typhoid  condition. 

Course. — Facial  erysipelas  and  the  idiopathic  cases  in  general  run  a  favor- 
able course,  as  a  rule,  and  subside  gradually.  Occasionally  the  subsidence  is 
by  crisis.  Convalescence  will  naturally  depend  upon  the  duration  of  the 
malady,  severity  of  the  complications,  and  the  age  of  the  patient.  In  ordinary 
cases  it  is  fairly  rapid. 

Reinfection  apparently  occurs  at  times  in  the  same  individual.  In  its 
migrating  form  erysipelas  will  gradually  attack  new  areas,  while  those  first 
invaded  are  completely  healed.  In  this  way  recovery  may  be  greatly  retarded, 
with  intervals  of  normal  or  even  subnormal  temperature. 

Mild  cases  subside  in  two  or  three  days.  Cases  of  ordinary  severity  with 
complications  last  about  six  or  seven  days.  Less  frequently  the  disease  is  pro- 
longed for  a  fortnight,  and  cases  have  been  reported,  especially  of  the  migrat- 
ing variety,  which  have  lasted  for  many  weeks. 

As  a  whole,  the  disease  is  less  fatal  and  of  somewhat  less  frequent  occur- 
rence now  than  formerly.  The  majority  of  the  idiopathic  cases  recover  com- 
pletely. Death  results  from  the  primary  toxic  effects  of  the  disease,  from 
exhaustion  and  cardiac  failure,  or  from  gangrene  and  other  complications, 
inducing  a  general  septic  condition. 

Complications. — Pneumonia  is  the  most  frequent  complication.  Purulent 
meningitis,  peritonitis,  and  inflammations  of  other  serous  membranes,  like  the 
pleura  and  pericardium,  have  been  observed  as  complications,  but  they  are 
comparatively  rare,  and  are  due  to  blood-poisoning  from  the  local  inflamma- 
tion rather  than  to  its  extension.  After  violent  maniacal  delirium  the  autopsy 
does  not  always  reveal  the  extension  of  inflammation  through  the  orbit  to  the 
meninges  or  brain.  The  inflammation  may  invade  the  larynx,  extending 
from  the  mouth,  and  it  may  pass  down  toward  the  lungs  and  be  complicated 
with  fatal  pneumonia.  Oedema  of  the  larynx  or  epiglottis  may  necessitate 
tracheotomy.  As  a  rule,  the  eyes  escape,  but  they  may  become  involved  in 
the  inflammatory  process  and  more  or  less  permanently  injured.  Gangrene 
occurs  in  the  loose  tissue  of  the  eyelids,  as  well  as  in  the  scrotum,  vulva,  and 
occasionally  in  the  mouth  or  pharynx  and  elsewhere  on  the  body.  The  writer 
saw  it  appear  on  both  feet  in  a  non-fatal  case.  It  is  usually  superficial.  The 
joints  are  sometimes  involved  by  extension  of  the  inflammation  to  their  serous 
surfaces  or  by  metastatic  abscesses,   but  this  is  more   common   in   surgical 


SEQ  UEL.E—  TREA  TMENT.  401 

cases.       Adenitis    and   lymphangitis  are    less  infrequent  accompaniments   of 
erysipelas. 

Sequelae. — The  sequelae  of  erysipelas  are  few  and  comparatively  unim- 
portant. The  hair  falls  if  the  disease  has  invaded  the  sctilp,  but  returns  again. 
Scars  may  be  left  by  extensive  sloughs.  Repeated  attacks  cause  permanent 
induration  of  the  skin  of  the  eyelids,  nose,  or  ears,  the  deformitv  amounting 
almost  to  elephantiasis  (Virchow).  Individuals  who  have  had  one  attack  are 
apt  to  have  another  after  an  interval.  Some  persons  have  an  attack  almost 
every  year.  They  are  apt  to  be  the  subjects  of  fistulse,  varicose  or  other  ulcers, 
ozaena,  and  the  like — conditions  which  maintain  a  favorable  seat  of  invasion 
by  inoculation.  Where  erysipelas  has  involved  previously  existing  patches  of 
chronic  eczema  or  lu})us,  the  latter  sometimes  show  decided  improvement  when 
the  invading  disease  has  gone.  After  erysipelas  has  passed  over  any  portion 
of  the  skin,  it  leaves  it  softer  and  finer  than  before  invasion.  Excei)tionallv, 
there  may  be  anaesthesia  or  hyperesthesia  of  the  inflame<l  area,  due  to  altera- 
tions in  the  structure  of  the  cutaneous  nerves.  Neuralgia  sometimes  ensues. 
Abscesses  may  form  in  the  eyelids,  or  there  is  rarely  keratitis  or  optic  neuritis. 

Diagnosis. — A  typical  case  of  erysipelas  is  not  likely  to  be  mistaken  for 
anything  else.  In  its  early  stages  it  has  been  confounded  with  urticaria, 
eczema,  and  other  skin  affections.  In  pemphigus  fever  is  absent  and  the 
bulla3  do  not  have  an  inflamed  base.  The  important  diagnostic  features  of  the 
erysipelatous  eruption  are  its  elevated,  clean-cut  margins,  its  peculiar  method 
of  spreading,  the  swelling  of  the  affected  skin  and  subcutaneous  tissue,  with 
tendency  to  form  blebs  and  bullae,  the  bright-red,  circumscribed  area  of  inflam- 
mation, which  contrasts  with  the  normal  skin  adjoining,  and  the  tendency  to 
exhibit  a  definite  relation  between  the  severity  of  the  eruption  and  the  height 
of  the  fever. 

Prognosis. — Erysipelas  occurring  in  previously  healthy  persons  runs  a 
favorable  course  in  a  large  majority  of  cases.  The  prognosis  is  bad  in  infants 
and  very  old  persons,  in  alcoholic  subjects,  and  in  those  who  are  debilitated 
from  long-continued  Avasting  diseases  of  tubercular  or  malignant  character. 
Occurring  in  the  })ncrperal  state,  the  disease  constitutes  a  very  grave  compli- 
cation, and  frequently  ends  fiitally.  As  a  general  rule,  the  prognosis  is  much 
less  favorable  in  the  traumatic  variety  than  in  facial  erysipelas.  As  a  compli- 
cation of  Brigiit's  disease,  erysipelas  is  greatly  to  be  dreaded.  If  the  disease 
be  epidemic  iii  a  crowded  habitation,  it  becomes  very  virulent.  The  gan- 
grenous form   is  very  fatal   from  sudden  collapse. 

Treatment. — ]\Iild  cases  of  facial  erysipelas  recover  spontaneously  without 
any  treatment.  Tliere  is  no  specific  remedy  for  the  disease,  and  atteni])ts  to 
abort  it  by  either  local  or  general  treatment,  while  apparently  successful  at 
times,  fail  completely  in  the  majority  of  cases.  The  indications  for  treatment 
are — 

I.  To  prevent  the  spread  of  the  contagion  to  others ; 

II.  To  keep  the  patient  comfortable  and  to])rev'ent  suffering  from  the  local 
inflammation  ; 

Vol.  I.— 26 


402  ERVSrrFJ.AS. 

III.   To  support  the  .stinigtli  by  stiimilants  and  nutritions  diet  ; 

TV.  To  deal  promptly  with  complications. 

J.  To  Prevent  the  Spread  of  the  ('ontdf/ioii  to  (Jtlier.s. — A  patient  havint^ 
either  variety  of  erysipela.s  should  be  isolated,  and  those  in  attendance  slioukl 
keep  awav  from  puerperal  patients  and  such  as  have  open  wounds,  and  they 
shoidd  carefully  protect  any  abrasions  on  their  o\\  n  persons,  and  maintain 
absolute  cleanliness  of  the  hands.  All  dressinj^s  used  about  the  patient  should 
be  destroyed  by  fire  ;  his  bed-linen  and  clothing-  should  be  disinfected  as  in 
the  case  of  any  contagious  exanthem,  and  any  instruments  used  about  him 
.«:hould  be  most  carefully  disinfected  afterward.  If  the  disease  develop  in  a 
hospital  ward  among  surgical  cases,  the  patient  must  be  isolated  and  the  ward 
em])tied,  thoroughly  fumigated,  and  disinfected  by  washing  with  corrosive-sub- 
limate solution.  Facial  erysipelas  has  been  treated  in  a  medical  ward  without 
its  spreading  to  other  medical  ]>atients,  but  it  is  always  best  to  isolate  such 
<'ases. 

II.  LoccJ  Treatiiient — The  local  burning  and  })ricking  may  be  relieved  by 
mild  astringent  and  soothing  applications.  A^aseline  oil  containing  5  per  cent, 
of  carbolic  acid,  linseed  oil  with  lime-water  (carron  oil),  are  useful  for  this 
purpose.  When  such  ipplications  are  made,  the  skin  should  first  be  gently 
washed  with  soap  and  warm  water,  and  the  preparation  then  slowly  rubbed  in 
around  the  infiamed  area,  the  friction  being  made  toward  the  affected  surface, 
not  away  from  it. 

Among  the  various  to])ical  applications  the  writer  has  obtained  the  most 
relief  by  the  use  of  a  mask  of  soft  lint  cut  to  fit  the  face  (with  holes  for  the 
eyes  and  nose),  which  is  frequently  wrung  out  in  a  cold  lead-and-opium  wash, 
such  as 

I^.    Ij\([.  [)hanbi  subacetatis,  f.5jss  ; 

Tinct.  opii,  f.lss  ; 

Aqua',  q.  s.  ad  fsviij. — M. 
Sig.    For  external  use. 

If  the  skin  be  very  tense  and  painful,  it  is  sometimes  more  benefited  by  a 
hot  poultice  than  by  c(^ld.  W  the  tension  be  extreme  and  gangrene  seem 
imminent,  small  linear  incisions  may  be  made  in  the  skin,  but  this  is  to  be 
avoided  if  j)()ssible.  Dusting  powders  relieve  the  burning,  but  have  the  dis- 
advantage of  obscuring  the  outlines  of  the  eruption.  In  order  to  limit  the 
spread  of  the  cutaneous  inflammation  caustics  have  been  vigorously  used,  :uh1 
even  incision  of  the  healthy  skin  has  been  tried  with  the  hope  that  the  advan- 
cing lesion  woidd  stop  at  such  barriers.  Strong  solutions  of  carbolic  acid,  caus- 
tic alkalies,  chloride  of  iron,  iodine,  turpentine,  nitric  acid,  ointments  of 
mercury  and  zinc,  ])owders  of  iodoform  and  resorcin,  subcutaneous  injections 
of  ])henic  acid,  and  the  actual  cautery,  have  all  l)eeu  tried  repeatedly  and  in 
turn  abandoned.  At  times  they  seem  to  temjwrarily  hold  the  march  of  the 
(lisease  in  check,  but  more  often  it  defies  their  limits,  and  is  even  aggravated 


TRKA  TMKNT.  403 

by  the  irritation  of  the  applications.     Koch  recommends  painting  the  inflamed 
snrface  witli  a  thin  hiver  of  the  foHowintr  mixture: 

R.    Creohn,  1  • 

Io(h)form,  4  ; 

Lanohn,  10. — M. 

Sitj.    For  external  nse. 


•r>' 


Elastic  conipression  of  the  intejj;nment  surronncling-  the  inflammation  has 
been  empl(»ye(l  in  some  instances  to  limit  the  inflamed  area  ;  and  contractile 
collodion  painted  over  the  surface  is  another  ap])licatioii  which  has  been 
used,  but  both  of  these  means,  while  they  are  (piitc  iiarmless,  are  of  uncer- 
tain advantay;e. 

If  the  cavity  of  the  mouth  be  invaded,  oarjrlos  of  alum  or  boric  acid  should 
be  used. 

III.  >S(iiitii/(()ifs  and  Diet. — The  diet  should  be  nutritious  and  adaj)ted  for 
easy  digestion.  If  the  fever  be  high  and  there  be  a  tendency  to  vomit,  nour- 
ishment should  be  given  in  small  quantities  and  at  very  frequent  interval.-^, 
as  every  hour.  In  ordinary  cases  peptonized  milk,  beef  juice,  egg-nog,  milk 
punch,  and  light  starchy  foods  are  given.  Stinudauts  should  be  prescribed 
freely  in  cases  which  begin  with  severity  or  in  milder  cases  where  the  syni])- 
toms  are  prolonged.  Alcohol  is  well  borne,  and  \S  or  20  ounces  of  whiskey 
or  brandy  given  in  twenty-four  liours  may  be  perfectly  assimilated  without 
toxic  effect.  If  the  pidse  be  feeble  or  irregular,  auimoniiuu  carbonate,  cam))h()r, 
tligitalis,  or  strophanthus  should  be  added  to  the  brandy.  Patients  in  whom 
the  disease  spreads  rapidly  over  the  body  require  particularly  energetic  stinui- 
lation.  The  tincture  of  the  chloride  of  iron  has  long  been  employed  in  Kng- 
land  and  the  United  States,  and  many  believe  that  it  is  a  speciflc  in  ervsi])elas. 
This  is  not  the  fact,  although  it  seems  to  beueflt  some  cases.  It  is  usuall\-  well 
tolerated,  even  if  u'iven  everv  two  houis,  in  half-drachm  doses  in  fflvcei-iii  and 
water. 

IV.  Trcdfiiiod  of  ('oinpU('cdio}\H  (Did  Vcrii  Srrrrr  Si/m/tfoms. — The  delirium 
is  best  controlled  by  hypodermic  injections  of  morphine,  or,  if  it  become  vio- 
lent and  maniacal,  by  the  one-hundredth  of  a  grain  of  hyoscine  hydrobromate, 
provided  that  the  heart-action  be  not  too  feeble.  An  ice-cap  shoidd  l)c  kept 
on  the  head.  The  tem|)cratui'e,  wlieii  high,  is  to  be  controlled  by  cold  alco- 
holic sj)onge-baths  or  wet  packs  and  compresses.  Antipyicti*-  drugs  should 
be  avoided  on  account  of  the  depression  which  they  cause.  Abscesses  should 
be  poulticed  and  evacuated  early.  (Jaugrcnous  areas  innst  be  <arefully 
dressed   with   disinfectants, 

Aftrr  recovery  from  the  infl.immation  the  patient  should  be  given  a  warm 
bath  containing  sodiiun  biearb(»nate,  and  then  the  surface  previously  inflamed 
shr)uld  be  sponged  with  a  1  :  .')0  solution  of  carl)()lic  acid,  niu'ing  convalescence 
great  care  shoidd  be  taken  to  avoid  excesses  in  food  or  drink  or  over-exertion. 
A  coiiisc  of  tonics,  siich  a-  iron  mid  cinchona  or  mix  vomica.  iiia\'  be  continued 


404  ERYSIPELAS. 

until  the  patient's  strength  is  fully  restored.     If  convalescence  be  greatly  pro- 
tracted, a  change  of  air  and  scene  is  indicated. 

Recent  experiments  have  shown  that  a  curious  antagonism  apparently 
exists  between  erysipelas  and  certain  forms  of  new  growths.  Inoculations  of 
]iure  cultures  of  Fehleisen's  erysipelas  coccus  have  been  made  upon  cases  of 
Ivmpho-sarcomata,  Avith  the  eifect  of  reducing  their  size  when  the  erysipelatous 
inflammation  subsides.  According  to  Kleeblatt,  the  cocci  multiply  within  the 
tumor  and  break  down  and  destroy  its  cells.  The  growth  is  considerably 
diminished  in  size,  and  a  temporary  improvement  results,  although  the 
tumor  may  return  again. 


i 


MALARIAL  FEVERS. 

By  W.  oilman  THOMPSON. 


Definition. — Malarial  fevers  constitute  a  group  of  miasmatic,  non-con- 
tagious, paroxysmal  fevers  in  which  the  principal  lesions  are  found  in  the  blood 
and  spleen. 

Synonyms. — Intermittent,  Periodic,  Marsh,  Swamp,  Miasmatic,  Malarial, 
or  Paludal  Fever ;  Ague ;  Fever  and  ague ;  Chills  and  fever ;  Fievre  palu- 
diene  (Fr.) ;  Wechselfieber  (Ger.).  The  term  "  malaria "  is  applied  to  a 
miasm  or  poison  which  begets  the  fever. 

The  chief  characteristic  of  a  malarial  fever  is  its  periodic  recurrence  or 
exacerbation  at  definite  intervals.  Each  exacerbation  is  termed  a  "  parox- 
ysm," and  the  typical  paroxysm  includes — (1)  a  cold  stage ;  (2)  a  hot  stage ; 
and  (3)  a  sweating  stage. 

On  Malarial  Fevers  in  General. 

Types  of  the  Malarial  Fevers. — There  are  two  primary  types  of 
malarial  fevers  :  I.  the  intermittent ;  II.  the  remittent.  The  first  is  charac- 
terized by  the  entire  absence  of  fever  between  the  paroxysms — the  second  by 
the  presence  of  more  or  less  fever  of  a  continued  type  which  does  not  cease 
between  the  paroxysms. 

The  paroxysms  may  recur  at  different  intervals,  and  the  principal  malarial 
fevers  are  named  in  accordance  with  the.se  intervals,  as  follows  :  I.  Quotidian  ; 
II.  Tertian  ;  III,  Quartan. 

The  "interval"  of  malarial  fevers  is  the  time  intervening  between  the 
beginning  of  one  paroxysm  and  that  of  the  next.  It  is  to  be  distinguished 
from  the  "remission"  or  the  "intermission,"  which  is  the  period  between 
the  end  of  one  paroxysm  and  the  beginning  of  the  next. 

In  quotidian  fever  the  interval  is  twenty-four  hours,  and  the  paroxysms 
return  daily  at  the  .same  hour. 

In  tertian  fever  the  interval  is  forty-eight  hours,  and  the  jiaroxysm  returns 
every  other  day  at  the  .same  hour,  or  on  every  third  day,  according  to  the 
Latin  method  of  counting  the  day  of  commencement  of  the  fever  as  the  first 
day  ;  hence  the  name  of  "  tertian  "  fever. 

In  (piartan  fever  the  interval  is  seventy-two  hours.  Other  malarial  fevers 
are  described  as  quintan,  sextan,  heptan,  and  octan,  the  names  denoting  the 
interval  between  the  paroxysms,  but  tiiesc  varieties  are  so  rare  as  to  be 
regarded  ratlier  as  curiosities  tiian  as  definite  types  of  ague. 

In  ordinary  ca.ses  of  simple  malarial   lever  of  whatever  type  the  parox- 

10,5 


40()  MA  LABIAL    FEVERS. 

y.sms  return  at  a  iiiiif'onn  liour,  ami  the  intervals  arc  consequently  uniform.' 
When,  however,  the  disease  is  becoming  nioi-e  severe,  the  interval  may  be 
shorte!ie(l  bv  half  an  hour  oi-  an  hour  or  two,  and  this  is  called  an  "  antici- 
j)ating"  fcv(!r.  It,  on  the  otiier  hand,  the  interval  is  similarly  ])rolonged, 
it  is  called  a  "postponing"  or  "retarding"  fever,  and  the  disease  is 
becomiuir  more  mild.  This  occui-s  not  intmiuentlv  under  the  influence  of 
treatment. 

The  average  length  of  the  paroxysm  in  each  ty[)e  of  intermittent  fever  is 
as  follows  :  In  (juotidian  intermittent  fever  it  is  ten  to  twelve  hours ;  in  ter- 
tian, six  to  eight  hours;  in  quartan,  four  to  six  hours.  It  is  unconimpn  for 
one  of  these  types  to  alter  to  another,  but  the  remittent  fevers  may  gradually 
terminate  by  becoming  intermittent. 

Hither  of  these  types  may  be  duplicated  in  the  same  individual,  as,  for 
exam{)le,  giving  double  quotidian,  tertian,  or  {|uartan.  In  the  double  quo- 
tidian two  distinct  paroxysms  of  nnecpial  intensity  occur  every  twenty-four 
hours. 

In  the  double  tertian  paroxysms  occur  at  the  usual  tertian  interval,  and 
milder  |)aroxysins  occur  besides  on  the  alternate  days,  but  at  a  different  hour 
from  the  others.  There  is  thus  a  severe  paroxysm  on  one  day,  a  mild  one 
on  the  Ibllowing  day,  then  a  severe  one  again,  and  so  on.  There  may  be 
two  tei'tian  paroxysms  occurring  on  the  same  day,  followed  by  a  free  day, 
and   then   by   two   more  pai'oxysms  on   the  third  day. 

In  the  double  (juartan  type  there  are  alternating  severe  and  mild  parox- 
ysms, with  one  free  day  between — /.  c.  there  is  a  severe  paroxysm  on  the  first 
day,  a  mild  one  on  the  second  day,  then  a  free  day,  followed  by  a  severe  par- 
oxysm, etc.  There  is  even  a  triple  quartan  type,  in  which  there  is  a  paroxysm 
every  day,  the  paroxysms  corresponding  at  four-day  intervals. 

The  tertian  and  quotidian  types  may  be  combined,  giving  two  paroxysms 
on  one  day,  one  on  the  next,  then  two  on  the  succeeding  day,  etc.  Most  of 
these  varieties,  excepting  the  first  form  of  double  tertian  described,  are  so  rare 
as  to  be  mere  curiosities. 

The  relative  frequency  of  quotidian  and  tertian  agues  in  the  United  States 
is  approximately  tlie  same,  the  quotidian  being  very  slightly  more  common 
than  the  tertian  variety.  The  prevailing  type  in  the  tropics  is  usually  quo- 
tidian, whereas  in  temperate  climates  it  is  frequently  tertian.  Quartan  fever 
is  rare  in  the  tropics,  and  is  infrequent  at  all  times,  seldom  constituting  over 
two  per  cent,  of  all  malarial  cases.  In  the  same  locality  all  these  forms  may 
coexist,  or  at  one  season  quotidian  ague  may  predominate,  while  tertian 
becomes  most  frequent  in  tlu;  next.  With  infants  the  quotidian  type  is  the. 
common  form  of  ague. 

The  malarial  ])ar()xysm  may  begin  at  any  time  of  day.  In  the  larger 
number  of  cases  quotidian  and  tertian  agues  begin  in  the  forenoon.  Quartan 
ague  usually  o(;curs  either  belbre  or  after  noon.  The  milder  types  of  ague  are 
more  regidar  in  the  hour  of  recurrence  than  are  the  more  severe. 

The  foregoing  cla«silication  of  malarial  intervals  may  apply  either  to  the 


OK   MALARFAL    FEVKIiS    IX    (,h\\/:h'AL.  4(i7 

intermittent  or  the  remittent  type  ;  thus  there  is  a  tiitiaii  intermittent  lever,  a 
tertian  remittent  fever,  ete. 

Etiology. — The  cause  ot'  all  malarial  fevers  is  noM'  sn])])0.sed  to  he  the 
])re.-ence   in   the   blood   of  a   speeifie  oruanism   (if  one  or   more  vai'ieties. 

The  Malarial  Germ. — The  malarial  parasite  is  a  proto/oon,  or  a  vegetable 
micro-organism,  whieh  inhabits  the  blood  of  man  and  eertoin  of  tiie  lower 
animals.  In  the  year  17KJ  an  Italian  |)hysician,  Laneisi,  lirst  attributed  the 
ori*>^in  of  malarial  fever  to  [)ois<)nons  (exhalations  arisin*;-  from  marshes.  In 
1879,  Klebs  and  Tommasi-Crndeli  succeeded  in  isolatin<r  a  uerm — Barilliifi 
malaria' — from  the  low-lyino-  atmosphere  ovei-  marshes  and  from  the  soil, 
which  they  inocidated  into  rabbits,  with  the  icsult  of  prodncin*:-  a  malarial 
])aroxy.sm   with  enlargement  of  the  spleen   and   pignientation. 

Laveran  in  1880  closely  followed  with  an  elaboi-ate  descri})tlon  of  the 
malarial  germ,  as  discovered  by  him  in  hinnan  blood  among  residents  of 
Algeria.  The  j)arasites  which  are  obtained  from  human  blood  in  the  conr>e 
of  malarial  fevers  exhil)it  several  varieties  of  form  and  size,  and  it  is  jiossible 
that  there  may  be  several  species  which  are  capable  of  exciting  the  distinct 
types  of  the  disease,  as  tertian,  quartan,  etc.  To  what  extent  these  various 
forms  are  related  to  one  another  as  different  stages  oi'  the  same  growth,  or  to 
what  extent  they  represent  different  species,  cannot  in  all  eases  be  detinitelv 
decided  at  present.  Laveran  is  inclined  to  think  that  the  malarial  gei"m  is  a 
.single  but  polymorphic  organism,  and  that  the  type  of  fever  depends  in  part 
on  the  particular  form  of  the  germ,  and  also  upon  the  condition  of  the  patient, 
his  tolerance  of  the  germ,  etc.  Osier  believes  that  difl'ereut  foi-ins  of  the  germ 
l)elong  to  distinct  species,  and  that  they  are  not  all  different  stages  in  the 
development  of  one  microbe. 

Laveran  describes  the  chief  forms  of  his  malarial  hematozoon  as  consi.sting 
of  (1)  amoeboid  spherical  bodies  with  miclei  ;  (2)  crescentic  shaj)es  with  nuclei; 
(3)  rosettes  ;  (4)  flagellate  bodies.  (See  Fig.  24).  The  Hagelhe  are  very  delicate. 
They  are  only  to  be  found  in   fresh  blood,  and  they  are  difficult  to  see  unless 

Fui.  24. 


f.:- 


Kiirms  of  the  llfimili>/.<""iii  of  Miliaria  lal'Icr  I.avfraii). 

they  are  in  motion.  The  other  forms  may  be  discovered  in  |)reserved  sjh'ci- 
mens.  His  method  of  examination  of  a  droj)  of"  blood  was  by  rapi<l  drying 
an<l  fixation  by  artificial  heat,  followed  by  stainjug  with  a  concentrated  so- 
lution ol  methvl-blue  or  gentian-violet.  (Sec  I'late.)  The  germs  may  be 
contained    in    the    blood-plasma   or   in    the   substance    of    the   red    blood-cells. 


408  3IALARIAL    FEVERS. 

The  name  plasmoduim  has  been  given  to  the  germ  found  in  tlie  red-blood 
disks.  The  observation  of  the  malarial  germs  in  human  blood  has  been  con- 
firmed by  Marchiafava,  Osier,  Councilman,  James,  Carter,  and  many  other 
competent  and  skilled  observers. 

Councilman  describes  the  flagellate  bodies  as  being  most  common  in  blood 
aspirated  from  tlie  sj)leen,  although  in  acute  cases  they  may  sometimes  appear 
in  other  situations.     They  exhibit  from  three  to  eight  vibrating  cilise. 

In  acute  malarial  fever  the  amoeboid  bodies  are  found  occupying  a  certain 
number  of  the  red  blood-cells  or  adhering  to  them.  They  derive  pigment 
(melanin)  from  these  cells,  and  after  undergoing  a  certain  development  and 
increase  in  size  at  the  expense  of  the  red  cells,  they  contain  this  pigment  in 
distinct  granules  and  rods.  During  the  paroxysm  they  must  undergo  seg- 
mentation. They  vary  in  size,  and  some  are  as  large  as  the  red  blood-disks. 
They  are  colorless  and  transparent. 

According  to  the  observations  of  Laveran,  the  crescentic  forms  of  the  germ 
are  common  in  the  blood  in  the  quartan  and  irregular  types  of  the  disease  and 
in  malarial  cachexia.  Like  the  amceboid  forms,  they  are  transparent  and 
colorless,  but  contain  pigment-granules  in  the  centre.  They  are  somewhat 
larger  than  the  diameter  of  the  red  disks,  and  the  ends  of  the  crescents  may 
be  joined  by  delicate  lines.  They  are  said  to  be  more  common  in  the  autumn 
than  at  other  seasons.  Quinine  acts  upon  the  amoeboid  form  of  the  parasite, 
and  antagonizes  or  gradually  destroys  it.  It  has  less  effect  upon  the  cres- 
centic form.  The  leucocytes,  or  active  white  corpuscles  of  the  blood,  are 
believed  to  antagonize  the  parasites,  and  spontaneous  recovery  from  malarial 
fever  is  attributed  in  part  to  their  destructive  action  upon  the  germs.  They 
may  either  act  directly  upon  the  germs  or  else  destroy  toxines  produced  by 
them. 

Golgi  believes  that  there  are  several  distinct  parasites  which  give  rise  to 
impaludism,  and  which  are  developed  periodically  or  in  a  rhythmical  manner. 
This  theory  accounts  for  the  paroxysmal  character  of  the  symptoms  of  ague, 
which  are  believed  to  correspond  with  the  various  stages  in  the  development 
of  the  germ.  He  considers  that  tertian,  quartan,  and  double  quartan  fevers 
are  due  to  germs  having  a  period  of  development,  or  life-cycle,  which  corre- 
S})onds  with  each  separate  variety  of  fever.  Golgi's  extensive  observations 
upon  the  malarial  organisms  (recently  published)  are  of  sufficient  interest 
and  importance  to  be  described  somewhat  at  length. 

In  tertian  fever  he  finds  a  plasmodium  in  the  blood  of  patients  several 
liours  before  the  onset  of  the  fever.  This  parasite  is  from  one-fourth  to  one- 
fifth  as  large  as  the  red  blood-disks,  and  it  exhibits  more  amoeboid  activity  in 
its  pseudopodia  than  is  shown  by  the  germs  in  other  forms  of  malarial  dis- 
ease At  first  it  contains  scarcely  any  pigment.  In  the  course  of  the  second 
day  tlie  plasmodium  increases  in  size  and  occupies  the  red  disks  at  the  expense 
of  its  substance,  filling  one-half  or  two-thirds  of  the  entire  corpuscle.  The 
])lasmodium  ai)propriates  the  pigment  of  the  red  disk,  and  converts  it  into 
.small  rods  and  granules  (Marchiafava  and  Celli).     The  plasmodium  grows 


ox  MA  LABIAL    FEVERS   IN   GENEBAL.  409 

more  distinct  and  the  red  disk  less  and  less  distinct,  until  the  latter  becomes 
scarcely  visible.  Finally,  all  the  pigment  of  the  red  disk  is  devoured  by  the 
organism,  and  the  pigment-granules  are  grouped  in  its  centre.  ISIeanwhile, 
the  organism  shows  a  tendency  to  subdivide.  Radiating  lines  mark  off  its 
substance  into  separate  masses,  and,  the  red  disk  having  tinally  disappeared, 
the  Plasmodium  liberates  its  pigment-granules  and  separates  into  a  number  of 
small  new  cells,  which  in  turn  attack  other  red  disks,  and  the  process  is  thus 
repeated  while  the  paroxysms  last.  Golgi  declares  that  the  appearance  of  the 
radiating  lines,  with  concentration  of  the  pigment  in  the  centre  of  the  amoe- 
boid cell,  is  an  indication  that  a  paroxysm  will  occur  at  once.  The  adminis- 
tration of  quinine  makes  it  difficult,  and  finally  impossible,  to  find  the  plas- 
modiuui  in  the  blood. 

In  tertian  ague  Golgi  has  found  the  malarial  organism  to  have  a  more  dis- 
tinct outline  than  in  the  quartan  form.  In  the  latter  it  is  coarser,  the  pigment- 
rods  and  granules  are  thicker  and  long  retained,  and  the  entire  development 
of  the  trerm  is  more  uniform  than  in  the  tertian  fever.  In  tertian  aoue  the 
parasite  completes  its  cycle  of  development  in  two  days,  whereas  in  quartan 
it  occupies  three  days.  In  tertian  ague  the  red  disks  may  be  swollen,  and 
they  certainly  are  not  shrivelled  as  in  quartan  fever.  The  two  forms  of  germ 
have  been  simultaneouslv  found  in  the  blood  in  some  instances.  iNIalarial 
fever  has  been  transmitted  from  man  to  man  by  inoculation  with  the  blood 
of  a  malarial  patient. 

Marchiafava  declares  that  in  Italy  the  malarial  parasites  are  subject  to 
variations  with  the  season  of  the  year — that  in  summer  they  occupy  the  red 
corpuscles,  and  if  the  fever  is  pernicious  they  are  associated  with  amoeboid 
bodies,  while  in  the  autumn  semilunar  and  filiform  shapes  are  more  common. 
The  latter,  he  says,  do  not  cause  fever,  but  the  amoeboid  bodies  excite  diurnal 
paroxvsms.  They  are  found  also  in  winter  and  spring.  Various  hsematozoa 
have  been  discovered  in  the  blood  of  certain  birds  and  other  animals,  espe- 
cially in  the  blood  of  apparently  healthy  animals  whose  natural  habitat  is 
marshes,  such  as  frogs,  lizards,  tortoises. 

The  germ  of  malarial  fever  taken  from  the  human  subject  and  injected 
into  birds  does  not,  howevei',  grow,  but  disappears.  Inoculated  in  rabbits, 
the  germ  produces  an  intermittent  fever  with  enlargement  and  pigmenta- 
tion of  the  spleen. 

Mode  of  Infection. — The  mode  of  malarial  infection  is  not  definitely  under- 
stood. The  miasm  often  seems  to  enter  the  system  through  the  medium  of 
inhalation,  while  at  other  times  it  apparently  enters  through  the  alimentary 
canal  by  means  of  contaminated  drinking-water  or  other  fluids  which  have 
been  exposed  to  a  malarial  atmosi)here.  It  is  never  transmitted  directly  from 
man  to  man  or  from  animals  to  man,  except  by  inoculation  experiments,  and 
it  is  not  known  that  the  germ  is  able  to  esca))e  from  the  body  in  any  manner. 
Presumably,  it  cannot  do  so,  since  it  is  only  found  in  the  blood,  ("oncentra- 
tion  of  malarial  patients,  therefore,  has  no  etiect  upon  the  spread  of  the 
disease. 


410  MALARIAL    FKVKRS. 

The  exact  relation  of  the  germ  to  the  symptoms  and  pathology  of  malarial 
fevers  is  yet  under  discussion.  AYhether  the  peculiar  conditions  of  the  nervous 
system  and  the  alterations  in  the  composition  of  the  blood  are  occasioned  by 
direct  irritation  of  the  j)lasmodinm  itself,  or  Avhether  they  are  due  to  toxines 
produced  bv  it,  are  questions  which  further  investigation  may,  solve. 

It  should  be  observed  that  there  are  still  many  competent  observers  who 
have  not  accepted  the  malarial  plasmodium  as  the  sole  cause  of  paludal  fever, 
arul  the  whole  subject  is  so  new  that  it  is  impossible,  as  yet,  fully  to  explain 
all  the  diiferent  clinical  phenomena  without  some  reserve.  It  is  certain,  how- 
ever, that  the  germ  exists  in  human  blood  during  and  between  malarial 
paroxysms  in  number  sufficient  to  exert  powerful  effects,  for  it  can  often  be 
f(»inid  in  almost  every  drop  of  blood  drawn.  Moreover,  it  is  never  discov- 
erable in  normal  blood  or  in  disease  other  than  some  form  of  ague.  In 
chronic  tonus  of  ague  and  in  doubtful  cases  the  |)resenee  of  the  germ  in  the 
blood  is  of  great  value  in  diagnosis. 

Race. — It  is  sometiiues  stated  tliat  negroes  are  less  susceptible  to  ague 
than  are  Europeans.  As  a  matter  of  fa(*t,  race,  apart  from  a  certain  degree 
of  acclimati/ation,  has  but  little  influence  upon  the  susceptibility  to  the 
malarial  fevers.  Natives  of  Central  and  Western  Africa,  although  they  may 
be  acclimated  at  home,  if  tlu^y  remove  to  another  part  of  the  country  are  quite 
as  liable  to  contract  malarial  fevers  as  are  foreigners  living  among  them 
(Parke).  In  the  United  States  negroes  are  somewhat  less  frequently  affected 
by  agues  than  are  other  persons.  In  India  the  mortality  from  lualarial  fever 
among  Hindus  and  Sepoys  is  as  high  as  among  the  resident  English  soldiers. 

Age  and  Sex  have  but  little  influence  upon  the  liability  to  affection  by 
malaria.  It  is  observed  at  any  age,  and,  although  it  is  not  very  common 
among  infants,  it  ma}'  occur  in  the  first  six  months  of  life.  Men  whose  occu- 
pation keeps  them  at  work  in  draining  marshes  and  upturning  malarial  soil 
an;  naturally  more  apt  to  be  affected  than  women  who  stay  at  home,  but  with 
ecjual  exposure  the  miasm  shows  no  ])referencc  for  one  sex  more  than  the 
other. 

Locdliiy. — Malarial  fevers  are  endemic  in  all  regions  excej)ting  in  the 
frigid  zones.  They  are  more  common  and  more  intense  in  the  tropics,  and 
gradually  become  less  common  and  less  severe  in  passing  away  from  the 
(•(piator.  In  Europe  they  are  centred  in  Italy,  especially  in  the  Roman 
Cam])agna,  and  in  the  marshes  about  the  lower  Danube,  In  the  United 
States  they  are  most  severe  in  the  South  and  South-west.  Latent  malarial 
fever  will  sometimes  develop  in  a  person  who  has  left  a  malarial  region  for  a 
locality  where  the  disease  never  originates. 

Heamn  and  Clhiude.-^—Xn  tropical  climates  malarial  fevers  ai'c  always  luore 
or  less  prevalent,  but  in  temperat(;  latitudes  they  do  not  prevail  in  very  cold 
weath(T,  an«l  they  are  most  commonly  developed  in  the  early  autumn,  when 
moderate  (-(dd  and  dryness  of  the  atmosphere  follow  a  damj)  season.  In  the 
United  States  ague  is  more  prevalent  in  the  spring  and  autumn,  less  common 
in  midsummer,  and  it  is  in  abeyance  iu  winter.      In  malarial  regions  exposure 


s 


OiV'    AfALA/i/AL    FEVKRS    IN    (.'/LXKIxWL.  411 

to  the  hot  sun,  mid  afterward  to  a  (h'aug;ht  <»<"  cold  air,  ol'tcii   precipitates  an 
attaek  of  ague. 

For  the  active  deveh)pnient  of  the  iiiiasin  a  temperature  of  60°  F.  or  more 
is  necessary.  In  temj)erate  latitudes  frequent  exposure  is  often  required  in 
order  to  develo|r malarial  fever.  In  tropical  ooinitries,  where  severe  forms  ot" 
ague  prevail,  the  exposure  is  not  necessarily  ]>rolonged  in  order  to  develop  a 
bad  attack.  Malarial  fevers  arc  undoubtedly  spread  by  winds.  There  arc 
manv  localities  in  whicii  the  wind,  ehanging  to  a  certain  direction  and  blow- 
ing across  an  infected  marsii,  will  provoke  outbreaks  of  fever.  This  is  espe- 
eially  true  in  regard  to  the  salt  marshes  near  Rome. 

The  malarial  germ  has  been  found  in  the  air  to  a  limited  extent.  A  heavv 
rainfall  washes  down  the  germs  from  the  atmosphere.  INIalaria  is  more  potent 
in  infection  at  night.  The  reason  for  this  is  ascribe<l  to  the  greater  concentra- 
tion of  the  cool  night  air  after  a  hot  day  has  rarefied  and  cxj)anded  the  atmo- 
sphere;  hence  anv  floating  germs  would  become  moi-c  concentrated  by  night. 
Extensive  fires  destroy  tiie  miasm. 

Soil. — The  soil  is  regarded  as  the  home  of  the  miasm,  and  nnder  certain 
conditions,  especially  when  miasmatic  earth  is  freshly  cx|)osed  to  the  air,  the 
germs  are  swept  uj)  by  air-currents  and  carried  off  in  the  lower  atmospheric- 
strata.  A  fresh-water  marsh  which  is  occasionally  overflowed  by  a  high  salt- 
water tide  is  particularly  liable  to  breed  malaria.  As  a  rule,  the  malarial 
poison  requires  moist  humid  earth  or  a  ujarsh  for  its  (level()])ment,  combined 
with  a  warm  temperature  and  ex])osure  to  the  air.  'I'lie  miasm  is  occasionally 
found,  however,  under  other  conditions.  It  is  met  with  on  dry  and  liot  sandy 
soil  in  Western  India  (jNIoore),  and  even  on  a  rocky  bed,  as  at  Hong  Kong 
(Maclean),  or  on  the  coral  rocks  of  Southern  Florida,  wheri^  vegetation  is  very 
scanty.  It  is  especially  virulent  along  seacoa.st  marshes  in  tro])ical  and  sub- 
tropical countries,  and  it  tends  to  follow  up  the  i)anl<s  of  i-ivei'>  from  their 
mouths.  It  flourishes  in  fresh-water  marshes,  but  ])artieularly  in  stagnant 
pools  and  in  marshes  near  the  sea  tainted  with  brine  and  not  elcani'd  freely 
by  the  tide.  It  has  been  known  to  develop  in  bilge-water  in  dirty  vessels 
at  sea. 

Malarial   fever  does  not  always  develop  in   pr<»portion   to  the  amount   ot 
decomposing  vegetable   matter  present.     Ovei'turning  the  soil    in   a   malarial 
region  or  removing  the  upper  layers  of  earth   usually  i^recipitatcs  an  outbreak 
of  malarial  fever. 

Malarial  fever  was  almost  unknown  in  the  island  of  Mauritius  up  to  the 
year  1865.  At  that  time  it  was  suddenly  contracted  by  immigrants  from 
India,  who  were  employed  in  draining  and  filling  a  nuid  flat.  Malarial  fevers 
at  times  ))revail  throughout  extensive  regions  for  years  until  cultivation  of  the 
soil  aixl  drainage  gradually  desti-oy  the  lionie  of  tlie  miasm.  On  the  other 
liand,  (cultivated  regions  when  abandonecl  may  again  Ixvunie  malarious,  as  tliey 
were  before  being  occupied  by  man. 

KleratUm  Above  the  Sm. — It  is  frequently  stated  that  malarial  fi'ver  does  not 
o<-cur  at  high  elevations,  but   this  is   n(»t   strictly  so.      WlsWo  it    is  true  that  it 


412  MALARIAL    FEVERS. 

flourishes  along  seacoast  marshes,  and  that  the  nn)st  malignant  types  of  fever 
are  found  in  low-lying  lands  generally,  it  may  be  present  elsewhere.  Thus 
Parke  speaks  of  encountering  it  near  tiie  Albert-Nyanza  on  a  dry  plain  at  4800 
feet  above  the  sea-level,  where  there  was  more  fever  than  in  the  lower  damp 
forest,  and  he  met  with  it  again  in  Africa  at  an  elevation  of  10,000  feet.  Ague 
is  common  in  the  elevated  plateaus  of  Northern  India.  I 

Antagonism. — It  has  been  claimed  that  a  certain  degree  of  antagonism  | 

exists  between  ague  and  phthisis.    This,  however,  is  not  the  case.    Ague  occurs  i 

in  connection  with  a  variety  of  chronic  and  acute  affections,  and  when  so 
doing  exerts  a  distinct  paroxysmal  influence  upon   their  course. 

The  lower  animals  may  contract  malarial  fever  independently  of  inocula- 
tion, but  it  is  not  common  among  them.  It  has  been  known  to  occur  in 
horses,  donkeys,  and  oxen. 

Classification. — For  convenience  of  description  it  is  customary  to  subdi- 
vide malarial  fevers  into  several  groups,  and  clinically  the  different  types  are 
verv  distinct.  It  should  be  borne  in  mind,  however,  that  anatomically,  as 
well  as  etiologically,  all  malarial  fevers  are  very  closely  related,  if  not 
actually  identical,  and  the  manner  in  which  one  variety  of  fever  may  occa- 
sionally merge  into  another,  or  in  which  two  types  coexist  in  the  same  indi- 
vidual, indicates  rather  a  diiference  in  degree  or  intensity  of  poisoning  than 
multiplicity  of  diseases.  The  final  outcome  of  the  present  study  of  the 
life-history  of  the  malarial,  germs  and  their  relations  to  the  symptomatology 
of  ague  is  anticipated  with  great  interest  in  regard  to  the  theory  of  the 
unity  of  malarial  fevers. 

Malarial  diseases  are  usually  classified  under  the  following  heads : 

I.  Intermittent  Fever ;  II.  Remittent  Fever  ;  III.  Pernicious  Intermit- 
tent Fever ;  IV.  Pernicious  Remittent  Fever ;  V.  Typho-malarial  Fever ; 
VI.  Malarial   Cachexia. 

I.  Intermittent  Fever. 

Morbid  Anatomy. — The  anatomical  lesions  of  intermittent  fever  are  few 
and  simple.  The  spleen  is  engorged  with  blood  during  the  febrile  paroxysm. 
It  is  enlarged  considerably  in  each  attack,  and  at  first  it  regains  the  normal 
size  during  the  intervals.  It  soon  fails  to  do  this,  and  finally  becomes  per- 
manently enlarged,  and  is  called  an  "  ague  cake."  In  exceptional  instances  it 
may  extend  to  the  umbilicus  or  below  it.  The  size  of  the  spleen  is  not  always 
an  indication  of  the  duration  of  the  disease.  In  not  a  few  cases  of  very  long 
duration  it  is  scarcely  enlarged  at  all,  while  it  may  suddenly  enlarge  very  much 
after  one  or  two  attacks.  A  rare  lesion  of  malarial  fever  is  rupture  of  the 
spleen,  producing  almost  instant  death  from  hremorrhage  into  the  peritoneal 
cavity.  The  spleen  occasionally  presents  hemorrhagic  infarcts  of  various 
.sizes.     Its  capsule  is  sometimes  adherent. 

The  liver,  like  the  spleen,  is  somewhat  engorged  during  the  paroxysm,  and 
the  hepatic  area  may  be  tender  on  pressure. 

Tiic  heart  is  sometimes  acutely  dilated,  though  this  accident  is  rare,  and  it 


I 


INTEIUnrTENT  FEVER.  413 

is  more  apt  to  occur  in  patients  rendered  antemic  and  debilitated  by  protracted 
attacks  of  ague. 

The  blood  during;  the  febrile  jiaroxysm  contains  fewer  than  normal  corpus- 
cles of  both  red  and  white  varieties.  The  condition  of  the  red  corpuscles  and 
their  pigment  has  already  been  detailed  in  the  description  of  the  malarial 
eerm. 

The  brain  and  spinal  cord  have  not  been  found  to  present  any  typical 
lesions,  but  it  is  believed  by  many  that  certain  of  the  prominent  symptoms  of 
ajirue  are  occasionetl  bv  functional  disorder  of  these  organs.  In  the  severe 
types  of  malarial  fever  they  are  pigmented. 

Incubation. — The  length  of  the  incubation  period  of  intermittent  fever 
depends  upon  the  intensity  of  the  miasm.  The  exact  limits  are  not  known, 
and  are  variously  stated,  from  an  hour  or  two  up  to  twenty  days.  There  are 
exceptional  cases  in  which  this  period  seems  to  last  for  several  months. 
Eichhorst  relates  the  case  of  a  patient  who  resided  for  some  time  in  a  mala- 
rious region  without  havins;  ague,  but  nine  months  after  leavinsi;  the  district 
and  residing  in  a  healthful  locality  he  was  attacked  by  intermittent  fever. 

During  the  incubation  period  there  may  be  no  symptoms,  and  the  patient 
be  in  apparent  health,  or  there  may  be  certain  indefinite  prodromata,  such  as 
malaise,  dyspepsia,  constipation,  dulness,  sleepiness,  irritable  temper,  etc. 

Symptomatology. — Intermittent  fever  presents  three  distinct  stages  :  (1) 
a  cold  stage;  (2)  a  hot  stage;  (3)  a  sweating  stage.  Collectively,  they  consti- 
tute the  malarial  "  paroxysm." 

The  cold  stage  is  characterized  by  subjective  sensations  of  cold  and  l)y  rigors, 
while  the  thermometer  records  an  elevation  of  the  internal  temperature;  the 
hot  stage  is  characterized  by  high  temperature  and  the  symptoms  of  pyrexia ; 
the  sweating  stage,  by  profuse  perspiration  and  the  subsidence  of  pyrexia. 

The  individual  symptoms  of  ague  vary  much  in  intensity  in  different  cases 
and  in  different  seasons  and  localities.  The  following  is  the  history  of  a  typ- 
ical case  of  intermittent  fever: 

History  of  a  Ti/picdl  CW.«r. — In  an  ordinary  case  the  chill  usually  comes 
on  gradually,  and  is  jireceded  for  two  or  three  hours  by  a  feeling  of  languor, 
dulness,  yawning,  and  headache.  In  some  cases,  however,  the  chill  begins 
very  violently  and  suddenly.  When  it  begins  slowly  the  malaise  is  followed 
by  a  chilly  feeling,  commencing  in  the  back  and  loins  and  gradually  extend- 
ing over  the  entire  body.  This  is  accompanied  by  muscular  tremors,  and 
sometimes  by  cramps.  There  are  often  nausea  and  vomiting,  which  arc  prob- 
ably due  to  congestion  of  the  stomach,  and  there  is  headache.  The  tongue  is 
l)ale  and  coated.  The  chill  becomes  more  and  more  violent;  the  teeth  chatter; 
the  surface  of  the  body  feels  cold  to  the  touch  ;  the  tips  of  the  fingers,  nose, 
and  ears  become  livid  ;  tliere  is  pronounced  pallor  of  the  features,  which  look 
shrunken  and  haggard  ;  and  the  skin  is  roughened,  dry,  and  presents  the 
appearance  of  "goose-flesh,"  or  cutis  anserina,  in  a  marked  degree.  There  is 
great  bodily  discomfort,  and  the  patient  calls  for  more  covering,  bii(  is  not 
relieved  by  it.     I'lie  museidar  rigors  become  so  violent  as  to  shake  the  entire 


414  MALARIAL    FEVERS. 

bed,  and  the  voice  is  feeble,  or  there  is  inability  to  speak  on  account  of  the 
constant  chattering  of  the  teeth.  The  respiration  is  hurried  and  short  and 
there  is  precordial  oppression,  and  sometimes  palpitation.  The  urine  may  be 
voided  in  increased  quantity.  During  this  time  there  is  a  gradual  accession 
of  fever.  The  surface  temperature  may  be  below  normal,  but  the  oral  and 
rectal  temperatures  show  an  increase  of  two  or  three  degrees.  The  peripheral 
vessels  an;  contracted,  so  that  the  prick  of  the  finger  fails  to  draw  blood.  The 
blood  passes  in  larger  volume  to  the  viscera,  producing  (congestion  of  the  more 
vascular  internal  organs.  This  congestion  accounts  for  the  gastric  or  enteric 
symptoms  which  accompany  the  disease,  and  it  interferes  grenrly  with  the 
fimctions  of  the  organs  affected.  The  greater  blood -pessure  of  the  internal 
vessels  in  organs  like  the  liver  and  spleen  modifies  their  nutrition  and  the 
elimination   of  waste  material. 

The  spleen  is  enlarged  during  the  paroxysm,  and  the  splenic  area  is  often 
quite  tender  on  [)ressure,  ami  a  sensation  of  fulness  may  be  experienced  there. 
The  luind  remains  clear. 

The  cold  stage  continues  for  a  varying  time.  It  may  be  very  mild  and 
unaccompanied  by  rigors,  lasting  but  a  very  brief  period — ten  or  fifteen  min- 
i,te.s — or  it  mav  be  prolonged  for  an  hour  or  two.  There  is  no  constant  rela- 
tion between  the  length  or  severity  of  the  cold  stage  and  that  of  the  hot  stage. 
The  cold  stage  is  said  to  be  shorter  in  the  quotidian  than  in  tertian  ague,  but 
Avith  the  hot  stage  the  reverse  may  obtain. 

The  average  diu-ation  of  the  chill  is  from  one-half  to  three-quarters  of  an 
hour.  In  young  children  the  chill  is  replaced  by  one  or  more  convulsions,  or 
else  the  first  stage  is  very  mild  or  wanting  altogether,  or  the  child  grows  sud- 
denly })ale  and  has  pronounced  ners^ous  symptoms. 

The  first  stage  passes  into  the  second  by  gradual  abatement  of  the  chill  and 
rigors,  which  are  replaced  by  a  feeling  of  warmth. 

The  second  or  hot  stage  is  characterized  by  fever  and  high  temperature. 
The  peripheral  vessels  now  have  their  constriction  relaxed,  and  the  pallor  of 
the  face  and  lividity  give  place  to  flushing  and  redness,  the  skin  feels  smooth, 
hot,  and  dry,  and  the  thermometer  in  the  rectum  records  103°,  105°,  or  106.5°, 
or  even  a  higher  temperature.  Respiration  grows  deeper,  and  the  pulse  is  full, 
bounding,  and  rapid — 130  or  more — and  it  is  frequently  dicrotic.  There  may 
be  an  anaemic  bruit  heai'd  at  the  base  of  the  heart.  The  patient  becomes  rest- 
less and  irritable,  but  the  mind  is  clear.  The  mouth  is  dry  and  the  throat 
])arched.  Sometimes  there  is  herpes  labialis.  There  is  continued  throbbing 
frontal  headache,  and  the  vomiting  may  be  repeated.  The  tongue  is  coated 
with  thick  white  fur,  and  the  breath  is  foul.  There  is  constipation.  There 
nuiy  be  slight  dizziness  or  a  "sinking  feeling,"  tinnitus  aurium,  and  muscjB 
volitantes.  This  stage  lasts  from  three  to  six  hours,  when  the  fever  gradually 
declines  and  tiie  patient  becomes  easier. 

The  third  or  sweating  stage  is  characterized  by  profuse  perspiration  and  the 
disaj)pearance  of  the  \'v\v\\  The  fever  may  subside  before  the  perspiration 
oc-curs,  or  it  may  continue  into  the  third  stage;  hence  the  perspiration  caniu)t 


JNTKR  MITTENT   FK  \  'KR. 


415 


be  regtirtled  as  the  cause  of  the  .subsidence  of  the  temperature.  The  sweating 
eoniniences  on  the  tureliead  and  face,  and  soon  the  whole  body  is  profusely 
bathed  by  it,  so  that  the  bed-clothing  is  thoroughly  wet.  The  j)ulse  becomes 
slower  and  returns  to  the  normal  tension,  and  the  spleen  gradually  i-eturns  to 
its  natural  size.  With  the  subsidence  of  the  tever  the  restlessness  disapjH'ars, 
and,  although  the  headache  may  continue,  the  j)atient  becomes  much  more 
comfortable,  and,  feeling  greatly  exhausted,  he  usually  [)asses  into  a  (juiet 
sleep,   from   which    he  awakens   more  or   less   fatigued. 

The  sweating  stage  lasts  from  two  to  four  or  six  hours.  The  entini 
})aroxysm  lasts  from  six  to  ten  or  twelve  hours,  according  to  its  severity.  In 
the  interval  between  two  paroxysms  the  patient  may  feel  in  perfect  health,  but 
there  are  apt  to  be  more  or  less  debility,  anorexia,  and  auicmia,  with  a  dimin- 
ishetl  number  of  red  blood-disks  and  a  reduced  quantity  of  luenu)globin  in  the 
blood. 

SPEt'iAi.  Symi'Toms. —  TtnniK'raiure  in  Intennittent  Fever. — The  tempera- 
ture, although  it  may  be  very  high   for  a  few  hours,  is  not  regarded  with  the 

Fig.  25. 


F 

107° 

106° 

105° 

104*^ 

10.V 

102" 

101° 

100° 

99° 

98° 

97° 

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solicitude  that  it  would  engender  in  other  affections.     The  same  degree  of  tcm- 
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416 


MALARIAL    FEVERS. 


subsides  of  its  own  accord.  Parke  ^  states  that  in  Africa  he  has  seen  every 
officer  of  the  Emin  Pasha  Relief  Expedition  "do  a  day's  march  with  a  tem- 
perature of  over  105°  F."  Of  course  this  was  exceptional  and  required 
undaunted  pluck,  but  in  many  other  diseases  the  same  degree  of  fever  would 
mean  utter  prostration  or  delirium  or  coma. 

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mum temperature  lasts  for  one  to  three  or  four  or  more  hours  according  to  the 
severity  of  the  paroxysm.  The  decline  is  sometimes  uniform,  but  it  is  fre- 
quently interrupted  by  "steps" — /.  e.  it  falls  one  or  two  degrees,  remains 
stationarv  for  half  an  hour  or  an  hour,  then  falls  again,  and  so  on  (Wunder- 
lich).  After  the  paroxysm  it  is  quite  common  for  the  temperature  to  drop  a 
degree  or  a  degree  and  a  half  below  the  normal  for  a  few  hours.  The  accom- 
panying temperature-charts  (Figs.  25  and  26)  illustrate  the  periodicity  of  the 
high  temperature  attained  in  the  quotidian  and  tertian  types. 


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Temperature-chart  of  a  Patient  with  Tertian  Intermittent  Fever. 

The  Urine. — After  the  chill  the  urine  is  often  increased  in  amount  and  is 
of  low  specific  gravity.  This  is  attributed  in  part  to  alterations  in  the  renal 
l)l()od-pressure   from  the  constriction  of  the  superficial  blood-vessels  of  the 

*  My  Personal  Experiences  in  Equatorial  Africa,  p.  424. 


INTERMITTENT  FEVER.  417 

body.  The  malarial  fever  gives  rise  to  waste  products  which  are  taken  up  by 
the  blood  and  eliminated  by  the  kidneys.  This  elimination  sometimes  attains 
its  maximum  before,  sometimes  during,  the  paroxysm.  There  is  always  an 
increase  in  the  elimination  of  urea  during  a  paroxysm,  and  Jaccoud  has  noted 
that  this  increase  commences  even  before  the  chill,  so  that  careful  quantitative 
estimation  of  urea  will  foretell  the  approach  of  a  paroxysm.  This  increase  of 
urea-excretion  he  observed  two  hours  before  the  chill  in  quotidian  and  six  or 
eight  hours  before  in  tertian  fever.  He  regards  the  estimation  of  the  increased 
urea  as  a  reliable  indication  for  the  proper  time  for  administering  quinine  in 
order  to  anticipate  the  chill.  Rarely  there  is  temporary  albuminuria  during 
the  pyrexia.     Temporary  glycosuria  has  also  been  reported  in  a  few  cases. 

Exceptional  Cases. — In  the  vast  majority  of  cases  of  malarial  fever  each 
succeeding  paroxysm  conforms  in  its  duration  and  stages  to  the  type  with 
which  the  disease  began,  but  this  is  not  invariably  the  case,  and  there  are  some 
curious  anomalies  in  the  type  itself.  Thus,  the  cold  stage  may  be  omitted 
entirely  or  the  sweating  stage  may  similarly  be  absent,  or  they  may  both  be 
wanting,  leaving  only  the  hot  stage.  When  the  chill  is  absent  the  disease  is 
sometimes  called  "dumb  ague."  This  form  is  more  common  among  the  older 
residents  of  a  malarious  rey-ion. 

In  severe  cases  of  intermittent  fever  the  several  stages,  and  especially  the 
hot  stage,  may  all  be  j^rolonged,  and  the  sweating  stage  of  one  paroxysm  may 
overlap  the  cold  stage  of  the  next.  In  rare  instances  the  cold  stage  may  be 
replaced  by  various  neurotic  symptoms,  such  as  neuralgic  pains,  general  ner- 
vousness, or  periodic  hysteria,  and,  if  the  temperature  be  high,  there  mav  be 
drowsiness,  partial  coma  or  delirium,  etc.  Intermittent  deafness,  blindness, 
vomiting,  diarrhoea,  and  asthma  are  all  symptoms  which  may  at  times  pre- 
dominate or  which   may  precede  a  typical  paroxysm. 

"  Latent  intermittent  fever"  is  a  name  given  to  a  condition  among  certain 
persons  living  in  malarious  regions.  There  are  no  definite  paroxysms,  but  the 
condition  is  best  described  by  the  term  "  bilious."  There  are  anorexia,  vomit- 
ing, headache,  constipation,  weakness,  and  lassitude.  Sometimes  there  is  a  very 
slight  periodic  elevation  of  temperature.  Such  persons  at  any  time  are  liable 
to  be  seized  with  a  veritable  paroxysm. 

"  Mofiked  malarial  fever'''  is  a  variety  of  intermittent  ague  which  is  commonly 
neuralgic.  The  ordinary  malarial  paroxysm  is  replaced  by  violent  neuralgic 
pain,  lasting  from  half  an  hour  to  six  or  eight  hours,  and  recurring,  like  the 
true  paroxysms,  at  regular  intervals.  Tliese  attacks  are  usually  unaccom- 
panied by  fever,  which  makes  the  diagnosis  still  more  diilicult.  The  nerves 
most  often  affected  are  the  supraorbital  or  infraorbital  branch  of  the  trigem- 
inus. Other  branches  of  that  nerve  may  be  affected,  or  the  sciatic,  the  nerves 
of  the  brachial  ))lexus,  or  intercostals.  In  cliildren  there  is  sometimes  bron- 
chial catarrh.  The  term  "  masked  ague"  may  also  refer  to  nudarial  fevers  in 
which  other  disorders  having  pronounced  symptoms  occiu',  such  as  ])ueuinonia, 
dysentery,  etc.,  and  which  by  their  greater   intensity  obscure  the  original  ague. 

Course. — Simple  intermittent  fever  runs  a  mild  course,  and  the  number  of 

Vol.  I.— 27 


418  MALARIAL    FEVERS. 

paroxvsms  may  be  cut  short  at  any  time  by  treatment,  by  removal  of  the 
patient,  or  by  change  of  season.  If  left  to  itself,  the  disease  may  run  on  for 
several  weeks  or  months,  and  in  a  bad  malarial  region  at  any  time  it  may  sud- 
denly be  converted  into  one  of  the  severe  types  of  ague.  Quartan  fevers  are 
often  more  obstinate  than  either  quotidian  or  tertian. 

Relapses  are  very  frequent  in  all  forms  of  ague,  and  they  may  undoubtedly 
occur  without  fresh  exposure  to  the  miasm,  as  may  be  the  case  with  sailors  at 
sea.  It  is  a  curious  feature  of  such  relapses  that  they  often  occur  on  the  day 
on  which  there  would  naturally  be  a  paroxysm  had  the  disease  been  uninter- 
rupted. A  relapse  at  periods  of  two,  three,  or  seven  weeks  is  sometimes  noted, 
or  the  interval  may  be  very  mnch  longer.  It  is  said  that  in  such  cases  there 
may  be  modifications  in  the  urine  with  increase  in  urea  corresponding  to  latent 
paroxysms.  While  there  is  any  elevation  of  temperature  indicated  by  the 
thermometer  there  is  very  likely  to  be  a  relapse,  or  if  the  spleen  remains 
enlarged  relapses  are  apt  to  occur. 

Sometimes  the  spleen  becomes  periodically  enlarged,  reaching  even  to  the 
umbilicus.  This  enlargement  is  accompanied  by  local  pain  and  tenderness, 
and  severe  vomiting,  while  the  chill  and  fever  may  be  entirely  absent. 
Between  the  attacks  the  engorged  spleen  returns  to  nearly  normal  size. 

Terminations. — The  majority  of  mild  cases  of  malarial  fever  recover  by 
themselves,  but  the  recovery  is  greatly  accelerated  by  apjjropriate  treatment. 
Severe  cases  become  more  or  less  chronic,  and  repeated  attacks  develop  the 
malarial  cachexia.  Even  the  graver  forms  of  malarial  fevers,  such  as  the  bil- 
ious or  haemorrhagic  types  of  remittent  fever,  are  frequently  amenable  to  treat- 
ment if  seen  early  and  if  treated  very  promptly.  Otherwise  they  may  prove 
fatal  from  various  causes. 

One  attack  of  malarial  fever  affords  no  immunity,  but,  on  the  contrary,  it 
is  apt  to  predispose  the  subject  to  others.  Secondary  attacks  may  occur  within 
a  few  weeks  or  after  an  interval  of  years. 

The  number  of  individual  paroxysms  that  the  same  person  may  have  at 
varying  intervals  while  in  a  badly- infected  district  is  sometimes  extraordinary. 
Parke ^  states  that  among  the  Europeans  who  crossed  the  continent  of  Africa 
on  the  Einin  Pasha  Relief  Expedition  the  average  number  of  separate  attacks 
was  one  hundred  and  fifty  for  each  man  in  a  period  of  three  years,  during 
which  time  they  marched  five  thousand  miles. 

Diagnosis. — The  diagnosis  of  malarial  fevers  is  easy  when  the  attack  is 
simple  and  typical,  and  Avhen  the  patient  can  furnish  a  clear  history  of 
exposure  or  of  previous  attacks.  It  is  far  more  common  to  mistake  other 
diseases  for  ague  than  to  err  in  the  opposite  manner. 

Simple  intermittent  fever  is  readily  distinguished  from  remittent  fever  by 
the  use  of  the  thermometer,  which  in  the  latter  demonstrates  a  continuance  of 
the  fever  in  the  interval  between  two  paroxysms.  There  are  usually  other 
symptoms  besides  the  temperature  that  persist  during  the  interval  in  remittent 
fever. 

*  My  Personal  Experiences  in  Equatorial  Africa,  p.  483. 


INTERMITTENT  FEVER.  419 

In  all  doubtful  cases  the  presence  of  an  enlarged  spleen  and  the  effect  of  a 
large  dose  of  qumine  will  aid  the  diagnosis.  The  quinine  can  scarcely  ever  be 
harmful,  and  its  prompt  employment  often  serves  to  clear  away  very  obscure 
symptoms. 

Moreover,  the  blood  should  always  be  examined  for  the  malarial  plasuio- 
dium.  This  is  easily  done  by  pricking  the  thoroughly  cleansed  finger  and 
drawing  a  minute  drop  of  blood,  which  is  to  be  flattened  out  into  a  very  thin 
layer  by  pressing  it  between  a  cover-glass  and  a  microscope  slide  until  the 
corpuscles  are  only  one  layer  deep.  The  slide  is  then  placed  under  a  high- 
power  lens  [^  oil-immersion),  when  the  germs,  if  present,  may  be  detected 
by  careful  search.  Osier  says  that  the  crescentic  forms  may  be  detected  with 
a  lower  power,  such  as  an  |^-inch  objective. 

The  sudden  occurrence  of  a  severe  chill  and  rigors  lastiug  three-quarters  of 
an  hour,  followed  by  a  sharp,  brief  fever,  the  temperature  reaching  105°  or 
more  within  a  few  hours,  is  very  suggestive  of  malarial  fever.  In  but  few 
other  affections  attended  by  an  initial  chill  is  the  latter  so  protracted  and 
severe.  It  is  exceptional  in  any  other  disease  for  the  temperature  to  reach 
such  an  elevation  so  suddenly  and  to  promptly  subside  again  to  the  normal. 

Pneumonia  may  be  ushered  in  by  a  severe  chill  and  rapid  rise  of  tempera- 
ture, but  the  subsequent  course  of  the  disease,  the  development  of  physical 
signs  in  the  chest,  the  sputum,  and  the  continuance  of  the  fever  will  soon  con- 
firm a  doubtful  diagnosis. 

Deep-seated  suppuration,  producing  sudden  general  septic  infection,  may 
be  mistaken  for  malarial  fever.  In  such  cases  a  searching  physical  examina- 
tion, with  a  careful  history  of  the  case,  the  absence  of  splenic  enlargement, 
and  the  lack  of  regularity  in  the  recurrence  of  chills,  fever,  and  perspiration, 
will  aid  in  eliminating  malarial  fever  from  the  diagnosis. 

Pulmonary  phthisis  is  occasionally  mistaken  for  ague  when  there  is  sup- 
puration with  recurring  chill,  hectic  fever,  and  perspiration.  In  such  cases 
the  correct  diagnosis  can  be  made  upon  a  thorough  physical  examination  of 
the  chest,  the  detection  of  tubercle  bacilli  in  the  sputum,  the  normal  spleen, 
and  the  negative  effect  of  quinine  upon  the  hectic. 

Catheterization,  or  the  passage  of  a  sound,  occasionally  produces  a  paroxysm 
resembling  that  of  ague. 

Prognosis. — The  prognosis  of  uncomplicated  intermittent  fever  is  most 
favorable  for  speedy  recovery  under  proper  treatment,  but  it  should  always  be 
remembered  that  in  a  region  where  malignant  types  of  the  disease  sometimes- 
occur  a  simj)le  unchecked  intermittent  fever  may  rapidly  merge  into  a  most 
j)ernicious  form  M'ith  fatal  issue. 

Prophylaxis. — To  some  extent  malarial  fevers  may  be  restricted  by  drain- 
ing and  filling  in  marshes  and  improving  the  general  sanitary  condition  of  a 

locality.  * 

Favorable  influence  has  been  attributed  to  the  eucalyptus  tree  (Eitcnlyptus; 
fflohulus)  planted  along  the  edge  of  marshes.  These  trees  grow  rapidly  and 
absorb  a  considerable  amount  of  moisture,  thereby  drying  the  marsh  ;  and 


420  MALARIAL    FEVERS. 

c]osely-j)lanted  trees,  like  high  fences,  prevent  the  dissemination  of  the  heavy 
malarial  poison  in  the  atmosphere  to  a  very  limited  degree.  Experiments  on 
a  large  scale,  as  made  by  the  French  in  Africa  and  the  Italians  near  Rome, 
have,  however,  failed  to  demonstrate  any  special  preventive  influence  from 
the  eucalyptus. 

Proper  attention  to  the  general  health  is  important.  Many  persons  living 
ill  a  uialarial  region  who  have  had  the  fever  find  that  when  they  allow  them- 
selves to  become  constipated  for  two  or  three  days  they  are  apt  to  precipitate 
an  attack  of  the  ague. 

Excesses  in  eating  or  drinking,  mental  strain,  ov^er-fatigue,  and  exposure 
should  be  strenuously  avoided.  Persons  are  far  more  liable  to  acquire 
malarial  fever  if  exposed  to  the  miasm  while  fasting  than  after  eating. 

Persons  living  on  the  upper  floors  of  buildings  in  a  malarial  region  are  less 
likely  to  have  ague  than  those  who  occupy  the  ground-floor  or  basement.  The 
susceptibility  to  the  miasm  is  greater  after  sunset,  at  night,  and  in  the  early 
morning  than  in  broad  day.  Sleeping  out  of  doors  should  be  especially 
avoided.  By  proper  attention  to  these  facts  many  persons  can  avoid  exposure 
while  residing  in  an  infected  locality. 

Those  who  are  obliged  to  live  in  malarial  regions  do  well  to  take  quinine 
in  daily  moderate  doses — three  or  four  grains  twice  a  day — and  arsenic  is  also 
of  value  as  a  prophylactic.  Fowler's  solution,  in  doses  of  four  to  six  minims 
well  diluted,  nray  be  taken  three  times  a  day  after  meals.  The  quinine  should 
be  taken  only  in  the  season  w^hen  ague  is  active,  for,  if  too  long  continued, 
the  system  after  a  time  becomes  accustomed  to  it,  and  very  large  doses  are 
required  to  obtain  any  effect  in  an  emergency. 

Care  should  be  exercised  to  maintain  the  general  health  by  proper  regula- 
tion of  the  diet,  bathing,  clothing,  exercise,  etc.,  and  it  is  important  to  av^oid 
constipation. 

Treatment. — The  chief  indications  for  treatment  are  to  prevent  the  return 
of  the  paroxysm,  to  restore  the  blood  to  a  normal  condition,  and  to  re-estab- 
lish the  functions  of  the  congested  viscera. 

The  urgency  with  which  ti'eatment  must  be  employed  in  the  various 
malarial  fevers  will  depend  upon  the  severity  of  the  case.  Fortunately,  in 
the  salts  of  quinine  we  possess  a  specific  for  malarial  fever,  and  in  very  mild 
cases  of  intermittent  fever  no  treatment  is  required  beyond  a  few  grains  of 
that  remedy.  In  severer  agues,  however,  prompt  and  energetic  action  is 
imperative  in  order  to  save  life,  for  it  may  result  in  the  rescue  of  appar- 
ently moribund  cases  of  the  worst  forms  of  pernicious  malarial  fever. 

Trcabaent  of  the  Chill. — When  a  paroxysm  of  ague  is  expected,  the  patient 
should  go  to  bed  and  keep  warm.  As  the  chill  approaches  a  diffusible  stimu- 
lant, such  as  aromatic  spirits  of  ammonia,  with  fifteen  or  twenty  drops  of 
chloroform,  may  be  given  with  some  simple  hot  drink.  Hot-water  bottles 
should  be  placed  at  the  feet.  Warm  blankets  are  needed.  An  opiate,  such 
as  Dover's  powder,  is  often  beneficial.  This  treatment  is  sometimes  successful 
in  aborting  the  chill,  and  it  may  lessen  the  severity  of  the  entire  paroxysm. 


INTi:h'JfITTEXT  FEVER.  421 

Treatment  of  the  Fevei\ — In  the  hot  stage  the  covering  should  be  lessened 
and  the  patient  may  be  sponged  with  cold  alcohol  and  water  in  equal  parts. 
Cooling  draughts  of  carbonic-acid  water,  Vichy,  or  lemonade  may  be  given. 
Except  for  the  administration  of  quinine,  described  below,  the  temperature 
rarely  requires  any  more  active  treatment,  as  its  duration  is  brief  in  any 
event.  During  the  sweating  stage  the  patient  is  made  more  comfortable 
by  having  the  perspiration  wiped  away  with  warm  cloths  as  fast  as  it 
forms. 

The  Administration  of  Quinine  in  Malarial  Fevers. — The  dos- 
age and  metiiod  of  administering  quinine  must  vary  somewhat  with  the  con- 
dition of  the  patient,  the  severity  of  the  attack,  and  the  quantity  which  the 
patient  may  be  accustomed  to  take.  Some  persons  are  put  in  a  state  of  most 
uncomfortable  cinchonism  bv  a  dose  of  five  grains,  while  others  are  not  dis- 
agreeably  affected  by  thirty. 

Small  doses  of  quinine  are  often  efficacious  in  those  persons  in  whom  cin- 
chonism is  readily  produced,  whereas  larger  doses  are  commonly  needed  by 
those  in  whom  toleration  is  much  greater.  In  very  mild  cases  five  or  ten 
grains  given  some  ho'urs  before  a  paroxysm  will  avert  it,  but  in  the  severer 
types  forty,  fifty,  and  in  very  malignant  types  even  one  hundred,  grains  must 
be  given  within  a  few  hours. 

Quinine  acts  most  promptly  when  administered  iu  solution,  but  the  taste 
is  so  bitter,  lingering,  and  difficult  to  disguise,  often  causing  vomiting,  that  it 
is  generally  preferable  to  give  the  drug  in  powder,  in  a  wafer,  in  black  coffee, 
or  in  a  soft  gelatin  capsule.  Pills  are  apt  to  become  hard  and  insoluble. 
AVhen  not  given  in  solution  quinine  is  rendered  more  soluble  and  assimilable 
by  prescribing  ten  or  fifteen  minims  of  dilute  hydrochloric  acid  to  follow 
each  dose.  Young  children  refuse  the  bitter  solutions  of  quinine,  and  they 
cannot  swallow  pills  or  capsules  :  in  such  cases  the  drug  may  be  given  in 
solution  or  suppository  by  the  rectum,  or  it  may  he  rubbed  into  the  abdom- 
inal wall  as  an  oleate  or  ointment.  In  this  way  the  constitutional  eilects  are 
usually  obtainable. 

Some  clinicians  give  quinine  at  stated  intervals  without  regard  to  the  par- 
oxvsms,  aimins:  merely  to  a(bninister  a  certain  dose  within  twenty-four  hours  ; 
and  in  very  mild  cases  this  will  accomplish  the  desired  result,  but  in  the 
majority  of  instances  it  is  better  to  prescribe  one  or  two  large  doses,  carefully 
timed  to  meet  the  paroxysm,  .so  that  one  dose  shall  not  be  eliminated  before 
the  next  exerts  its  influence.  Thirty  to  forty  grains  given  four  to  five  houi-s 
before  the  paroxysm  in  a  very  severe  case  will  accomplish  far  more  than  if  the 
same  amoiuit  be  distributed  throughout  the  day,  for  it  is  quickly  eliminated 
from  the  system. 

It  is  sometimes  desirable  to  precede  the  quinine  by  a  purgative  dose  of 
calomel,  for  the  bowels  are  apt  to  be  constipated,  the  tongue  coated,  and  the 
patient  more  or  less  "bilious;"  but  it  is  not  advisable  ever  to  delay  the 
administration  of  the  quinine  on  this  account.  In  severe  cases  of  the  ]ier- 
nicious  fi)rm  it  is  higldy  injurious  t(t  weaken  the  patient  by  purgation,  and  it 


422  MALARIAL   FEVERS. 

is  a  mistake  to  drive  the  quinine  out  of  the  alimentary  canal  by  calomel  before 
it  has  had  time  for  complete  absorption. 

It  is  of  no  use  whatever  to  give  quinine  during  a  paroxysm  of  simple 
intermittent  fever,  for  it  requires  so  long  a  time  for  its  complete  influence 
upon  the  system  to  be  established  that  tlie  paroxysm  is  over  before  it  can  be 
absorbed.  In  fact,  it  is  very  often  vomited  when  taken  during  the  seizure.  It 
is  from  four  to  six  hours  after  the  administration  of  quinine  before  its  maxi- 
mum effect  is  attained.  In  quotidian  fever  quinine  should  be  given  eight 
hours  before  the  expected  chill,  because  the  real  onset  is  two  hours  before  the 
chill.  In  tertiary  fever  it  should  be  given  twelve  hours  before,  and  in  quartan 
fever  fifteen  or  eighteen  hours  before,  and  repeated.  A  fifteen-grain  dose  of 
quinine  given  only  two  hours  before  or  given  during  a  paroxysm  does  not 
affect  it,  but  given  at  the  close  of  one  paroxysm  it  aborts  the  next  paroxysm 
either  wholly  or  in  part.  It  may  have  to  be  continued  in  this  manner  for 
four  or  five  days  before  the  fever  entirely  ceases,  and  quinine  should  be 
taken  in  smaller  doses  for  a  week  or  two  thereafter. 

The  effect  of  quinine  in  intermittent  fever  is  to  prevent  a  second  paroxysm 
only  in  a  certain  number  of  milder  cases.  In  other  cases  it  either  postpones 
the  next  paroxysm,  or,  without  postponing  it,  renders  it  much  milder  than  it 
presumably  would  have  been,  causing  the  chill  to  be  abbreviated  or  omitted. 
A  third  paroxysm  is  usually  prevented  by  the  quinine. 

Many  believe  that  o[)ium  acts  as  an  adjuvant  to  quinine  in  controlling 
malarial  paroxysms.  Schauffler  recommends  the  bromide  of  potassium  in 
doses  of  forty  to  eighty  grains  to  relieve  cinclionism  and  quiet  the  nerves. 

In  certain  patients  quinine  possesses  but  little  influence  over  the  fever. 
This  may  be  due  to  some  idiosyncrasy  or  to  the  fact  that  the  system  from 
long-continued  use  of  the  remedy  has  become  inured  to  it.  Warburg's  tinc- 
ture and  arsenic  may  then  be  of  service.  The  former  is  a  compound  remedy 
which  has  been  long  used  in  India  and  elsewhere.  Besides  preparations  of 
cinchona,  the  original  formula  contained  chiefly  aloes,  rhubarb,  opium,  and 
camphor.  A  modified  Warburg's  tincture  is  prepared  by  omitting  the  aloes 
and  some  of  the  minor  ingredients.  This  remedy  has  a  very  disagreeable 
taste,  and,  since  the  dose  is  f^ss  in  water,  it  is  apt  to  prove  nauseating.  It 
may  be  given  by  the  rectum,  where  it  is  usually  well  borne,  or  in  pill  form 
after  evaporation,  but  the  latter  method  is  not  so  efficacious.  Warburg's  tinc- 
ture sometimes  succeeds  in  breaking  up  obstinate  malarial  fevers  when  quinine 
has  failed.  It  is  of  more  use  in  the  severer  forms  of  ague  than  in  simple 
intermittent  fever,  and  quinine  may  be  given  in  combination  with  it.  Besides 
controlling  the  fever,  it  has  to  some  extent  a  sudorific  action. 

Arsenic  is  administered  as  arsenious  acid,  one-thirtieth  of  a  grain  thrice 
daily,  in  pill  or  in  the  form  of  Fowler's  solution,  liquor  potassii  arsenitis,  four 
to  six  minims  thrice  daily,  after  meals,  w^ell  diluted.  It  is  often  useful  to 
combine  this  drug  with  iron  on  account  of  the  anaemia,  which  is  more  or 
less  marked.  Neither  Warburg's  tincture  nor  arsenic  have  any  effect  upon 
a  paroxysm  already  begun. 


REMITTENT  MALARIAL    FEVER.  423 

Many  attempts  have  been  made  to  find  substitutes  for  quinine  for  use  in 
those  cases  in  whicli  it  is  not  well  tolerated.  Other  jM-eparations  of  cinchona, 
such  as  quinidina,  chinoidina,  cinchonidina,  have  all  been  used.  Salicin  in 
doses  of  a  drachm  in  twenty-four  hours,  strychnine  and  nux  vomica,  ammo- 
nium chloride  and  eucalyptol,  with  a  long  list  of  other  remedies,  have  been 
faithfully  tested  for  antiperiodic  action,  but  none  of  them  can  really  replace 
quinine. 

n.  Remittent  Malarial  Fever. 

This  fever,  from  the  prominence  of  the  gastro-intestinal  symptoms,  is  often 
called  bilious  remittent  fever  or  gastric  fever.  This  type  of  ague  is  charac- 
terized by  the  same  symptoms  that  occur  in  intermittent  fever,  but  the  tem- 
perature continues  elevated  through  the  interval.  It  is  supposed  to  be  due  to 
a  greater  intensity  of  action  or  of  concentration  of  the  miasm,  or  to  a  greater 
.susccjitibility  on  the  part  of  the  patient. 

Morbid  Anatomy. — In  fatal  cases  of  remittent  fever  the  characteristic 
lesions  are  a  deep  pigmentation  of  the  spleen,  liver,  and  brain,  and  the  ])res- 
ence  in  the  blood  of  free  altered  blood-pigment — a  condition  known  as  melan- 
semia.  Organs  having  deposits  of  such  pigment  are  said  to  be  in  a  state  of 
melanosis.  The  pigment  occurs  in  granules.  It  is  found  in  remittent  fever, 
in  ])ernicious  malarial  fevers,  and  occasionally  in  protracted  intermittent  fever 
and  malarial  cachexia. 

The  pigment  in  melana^mia  forms  Prussian  blue  when  tested  with  the 
ferrocyanide  of  potassium  ;  hence  the  iron  which  it  contains  does  not  all  exist 
as  an  organic  compound.  The  extent  of  discoloration  of  the  different  organs 
affected  varies  with  time.  In  recent  cases  they  are  slightly  darker  than 
normal,  but  in  protracted  cases  they  are  deejjly  bronzed  or  of  a  grayish  or 
bluish-black  color. 

The  spleen  is  at  first  hyperfemic,  soft,  and  swollen,  but  as  the  paroxysms 
return  it  fails  to  contract  in  the  interval,  and  it  gradually  becomes  perma- 
nently hypertrophied  and  firm,  instead  of  remaining  soft.  There  is  hyper- 
plasia of  the  connective-tissue  elements  of  the  organ.  The  pigment  is  found 
deposited  within  the  lymphoid  splenic  cells  in  granular  masses.  It  is  also 
found  around  and  in  the  walls  of  the  veins. 

The  liver  is  enlarged,  but  in  old  cases  it  may  be  atrophic  (Flint).  It  is 
often  hyperaemic,  and  is  strongly  pigmented.  It  is  commonly  called  the 
"bronze  liver."  Pigment  is  found  in  granular  masses  both  in  and  between 
the  lobides,   in  the  vessels,  and  vessel-walls. 

The  marrow  of  the  long  bones  is  similarly  pigmented.  The  granules  are 
foinid  in  the  lymphoid  cells,  around  and  within  the  blood-vessels. 

The  gray  matter  of  the  brain  is  dark  gray  or  almost  black.  In  severe  cases 
the  white  matter  is  also  pigmented,  and  it  exhibits  minute  luemorrhages,  which 
arc  thought  to  be  produced  by  emboli  oC  small  masses  of  j)igment  which  enter 
the  ca|)inaries  and  occlude  them.  Jn  tlic  brain,  as  elsewhere,  the  j)igment  is 
foimd  in  the  walls  and  outside  of  the  blood-vessels. 


424 


MALARIAL    FEVERS. 


Other  vascular  organs,  such  as  the  pancreas,  thyroid  gland,  kidneys,  the 
mucous  membranes,  lymphatic  glands,  and  the  skin,  are  more  or  less  pig- 
mented. There  may  be  ecchymoses  in  the  mucous  membranes  of  the  ali- 
mentary canal. 

Symptomatology. — This  variety  of  fever  is  apt  to  begin  with  a  more  pro- 
nounced paroxysm  than  occurs  in  intermittent  fever,  although  the  cold  stage 
may  be  more  brief.  Sometimes,  however,  there  are  prodromata,  such  as  may 
precede  any  febrile  disease,  or  there  may  first  be  one  or  two  mild  intermit- 
tent paroxysms. 

When  \\\e  paroxysm  commences  there  is  a  good  deal  of  nausea  and  eraesis, 
which  continue.  Often  large  quantities  of  bile  are  vomited.  There  are  ten- 
derness over  the  epigastrium  and  splenic  area  and  loose  watery  diarrhoea.  Not 
infrequently  there  is  jaundice.  The  temperature  is  high,  often  rising  to  106° 
F.  or  higher.  The  second  stage  of  febrile  exacerbation  often  lasts  for  a  Ionu:er 
period  than  in  intermittent  fever,  and  it  may  not  subside  before  twelve  or  even 
twenty-four  hours.   (See  Fig.  27.)     In   milder  cases  the  temperature  falls  in 

Fig.  27. 


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throe  hours.  This  is  followed  by  a  sweating  stage  of  moderate  degree,  and 
the  fever  continues  at  101°  to  103°  F.  until  the  next  paroxysm.  In  the  sec- 
ond paroxysm  the  chill  is  frequently  omitted. 

During    the    interval,    besides    the    increased    temperature   there    may    be 
nausea,   lassitude,  and   muscular  soreness.     The  frequency  of  the  paroxysms 


PERNICIOUS   INTERMITTENT  FEVER.  425 

may  correspond  to  any  type,  quotidian,  tertian,  etc.  After  about  a  week  of 
severe  fever  the  pyrexia  gradually  subsides,  and  in  another  week  or  two  it  dis- 
appears and  the  patient  recovers.  The  fever  may  subside  by  becoming  con- 
tinuous and  slowly  decreasing,  or  it  is  not  uncommon  for  it  to  pass  into  a  dis- 
tinct intermittent  type  and  end  in  that  manner.  The  remission  usually  com- 
mences between  juidnight  and  the  early  morning.  Occasionally  the  disease 
ends  by  crisis. 

Duration. — The  duration  of  the  disease  can  be  curtailed  by  treatment.  It 
may  last  anywhere  from  three  or  four  days  to  three  weeks,  or  it  is  still  further 
protracted,  and  the  patient  may  pass  into  the  typhoid  state.  As  a  rule,  remit- 
tent fever  is  more  grave  than  intermittent  ague. 

Complications. — Remittent  fever  may  occur  in  connection  with  many 
other  diseases  or  be  complicated  by  them.  Among  the  more  frequent  compli- 
cations are  to  be  mentioned  acute  nephritis,  dysentery,  and  lobar  pneumonia. 

Diagnosis. — Remittent  fever  is  liable  to  be  confounded  with  typhoid  fever 
and  with  certain  eases  of  yellow  fever  occurring  at  the  commencement  of  an 
epidemic.  Since  this  is  also  true  of  the  pernicious  type  of  ague,  the  diagnosis 
will  be  considered  in  connection  with  that  disease.     {Vide  infra.) 

Prognosis. — The  prognosis  for  simple  remittent  fever  is  favorable.  In 
this  type  of  malarial  fever  there  is  more  danger  than  in  intermittent  fever  of 
sequelae,  such  as  extreme  anaemia,  "  ague  cake,"  and  dropsy.  The  disease  is 
much  more  severe  in  hot  climates  than  in  temperate  regions. 

Treatment. — The  treatment  involves  the  early  production  of  cinchonism, 
as  in  the  intermittent  type.  Large  doses  of  quinine,  twenty  to  thirty  grains, 
should  be  given  every  three  or  four  hours  until  there  are  ringing  in  the  ears 
and  throbbing  of  the  temples.  It  is  not  necessary  to  await  the  termination  of 
the  paroxysm,  but  the  quinine  should  be  begun  at  once,  for  it  is  the  prolonged 
hot  stage  which  especially  demands  attention.  As  a  rule,  severe  purgation  or 
any  depleting  measures  should  be  avoided.  In  certain  cases,  however,  when 
the  bowels  are  very  constipated,  the  tongue  thickly  coated,  and  the  urine 
diminished  and  overloaded  with  solids,  a  dose  of  calomel  or  of  blue  mass 
is  indicated.  Care  must  be  taken  not  to  hurry  off  the  quinine  by  ])urgation  ; 
and,  if  the  (juinine  has  just  been  given,  the  bowels  can  be  moved  by  a  stimu- 
lating enema  of  half  an  ounce  of  tur})entine  and  an  ounce  of  castor  oil  in  a 
pint  of  warm  soaj)Suds. 

If,  on  the  other  hand,  severe  diarrhoea  or  depressing  emesis  exist,  such 
symptoms  should  be  controlled  by  an  opiate,  and  poultices  or  hot  turpentine 
stupes  placed  upon  the  abdomen.  Wiien  the  kidneys  are  congested,  mi]<l 
saline  diuretics,  such  as  potassium  citrate  or  bitartrate,  may  i)e  given  with 
refrigerant  or  effervescing  drinks,  such  as  Vichy,  acid  hMiumade,  (■ari)()ni('-a('i(l 
water,  etc. 

TTT   Pernicious  Intermittent  Fever. 
Pernicious  intermittent  fever  is  also  called  malignant,  irritativ(>,  and  conges- 
tive intermittent  fever  or  congestive  chills.     As  the  name  implies,  it  is  a  very 


426  MALARIAL    FEVERS. 

severe  type  of  ague.  In  the  late  Civil  War  in  the  United  States  this  type  of 
fever  constitnted  nearly  24  per  cent,  of  the  mortality  from  disease.  It  is  a 
relativelv  uncommon  form  of  malarial  fever,  but  it  aj)pears  from  time  to  time 
in  tropical  countries,  and  in  the  United  States  in  the  South  and  West. 

The  disease  may  commence  in  a  malignant  manner  and  he  fatal  at  once,  or 
it  may  be  ushered  in  by  one  or  more  paroxysms  of  ordinary  severity.  When 
one  })aroxysm  grows  very  severe,  the  following  one  is  frequently  fatal.  The 
pernicious  tvpe  soon  becomes  manifest  through  one  or  more  of  the  following 
features :  deepening  coma,  delirium,  violent  vomiting  and  purging  with  blood 
and  mucus  in  the  stools,  intense  weakness,  hsematuria  with  hgemorrhage  from 
various  mucous  surfaces,  and  collapse. 

The  prominence  of  certain  of  these  symptoms  in  pernicious  malarial  fever 
makes  it  convenient  to  subdivide  the  disease  into  several  varieties,  which  will 
be  briefly  described  under  the  following  heads  : 

I.  Bilious  intermittent  fever,  in  which  the  gastro-intestinal  irritation  with 
vomiting  of  bile  is  the  most  striking  symjjtom  ; 

II.  The  hsematuric  or  hsemorrhagic  variety,  with  bloody  urine  and  hsem- 
orrhages  from  muccKis  surfaces  ; 

III.  The  asthenic  form,  with  great  prostration  and  feeble  circulation  ; 

IV.  The  algid  form,  resembling  the  algid  stage  of  Asiatic  cholera ; 

V.  The  comatose  variety,  with  sudden  and  profound  unconsciousness. 
Symptomatology. — I.  Bilious  Intermittent  Fever  may  attack  the 

]>atient  very  suddenly,  the  first  symptom  being  a  severe  chill  and  vomiting,  or 
it  may  be  preceded  by  dyspeptic  symptoms,  constipation,  flatulence,  a  coated 
tongue,  and  offensive  breath,  with  muscular  pains.  In  patients  who  have  had 
several  attacks,  often  one  of  the  first  symptoms  noticed  is  an  extreme  irrita- 
bility of  temper  with  great  mental  and  bodily  restlessness.  There  is  frontal 
headache,  the  muscular  pains  increase,  and  the  entire  body  aches.  The  pains 
are  mostly  in  the  loins  and  knees,  and  sometimes  they  begin  quite  suddenly,  as 
though  the  muscles  had  been  pounded.  These  pains  are  occasionally  so  severe 
as  to  require  morphine  for  their  relief.  There  are  often  cramps  in  the  muscles 
of  the  calves.  The  pulse  is  rapid  and  the  heart-action  irritable.  Pallor  is 
succeeded  by  congestion  of  the  face  and  injection  of  the  eyes,  which  acquire  a 
typical  staring,  glistening  appearance.  The  temperature  rises  to  105°  or  106.5° 
F.,  or  even  higher.  The  vomiting  begins  early  and  continues.  Large  quan- 
tities of  bile  may  be  ejected.  Pressure  over  the  stomach  and  liver  is  painful. 
The  prostration  is  very  great  and  there  is  rapid  emaciation. 

In  severe  cases  there  is  a  sense  of  fulness  or  constriction  in  the  chest,  and 
neuralgic  pains  may  be  felt  in  the  larger  nerves,  as  the  sciatic,  median,  or 
anterior  crural.  The  spleen  becomes  greatly  enlarged,  and  the  splenic  region 
mav  be  more  or  less  tender.  There  are  increasing  anfemia,  and  decided  consti- 
pation  from  lack  of  power  in  the  muscular  coat  of  the  intestine.  The  urine 
becomes  dark,  of  high  specific  gravity,  is  loaded  with  urates  and  phosphates, 
and  may  contain  blood  or  bile-pigment.  In  some  cases  rapidly-deepening 
jaundice  is  a  prominent  symptom,  coming  on  within  five  or  six  hours. 


PERNICIOUS   INTERMITTENT  FEVER.  427 

In  certain  cases  of  bilious  intermittent  fever,  as  in  the  simple  form,  the 
chill  and  sweating  are  absent,  the  recurrent  fever  being  the  main  symptom. 
In  other  cases  the  chill  and  fever  are  present,  but  the  third  stage,  that  of 
sweating,  is  omitted. 

In  an  intestinal  variety  there  are  frequent  diarrhoeal  stools,  with  flatulence, 
tormina,  and  abdominal  distension  and  tenderness,  especially  over  the  stomach 
and  liver.  The  stools  contain  large  quantities  of  mucus,  and  at  times  they 
become  so  copious  and  watery  as  to  suggest  choleraic  discharges,  or  they  con- 
tain blood  and  mucus,  as  in  dysentery. 

II.  The  H.ematuric  Type. — The  haematuric  or  hemorrhagic  form  is 
always  very  serious.  The  paroxysm  commences  with  a  prolonged  chill  and 
rigors,  and  the  temperature  rises  rapidly.  In  the  second  stage  blood-disks 
and  blood-pigment  appear  in  the  urine,  which  is  diminished  in  quantity  and 
contains  more  or  less  albumin  with  granular  and  bloody  casts.  The  patient 
a})pears  very  ill  and  is  restless  and  anxious.  Soon  a  condition  of  general  pur- 
j)ura  develops  :  there  are  ecchymoses  into  the  skin,  and  there  are  epistaxis, 
haemorrhage  from  the  mouth,  stomach,  rectum,  or  vagina.  The  skin  becomes 
more  and  more  yellow,  or  even  of  a  bronze  hue.  Suppression  of  urine  is  apt 
to  occur,  and  then  the  toxic  condition  of  uraemia  is  added  to  the  existing 
blood-poisoning.  The  emesis  continues  :  there  are  violent  headache,  delirium, 
and  finally  deepening  coma,  with  Cheyne-Stokes  respiration,  a  rapidly  failing 
heart-action,  pulmonary  oedema,  and  death.  These  haemorrhagic  symptoms 
may  occur  in  either  pernicious  intermittent  or  remittent  fever.  In  less  severe 
cases  the  mind  remains  clear  throughout.  When  delirium  or  coma  ensues  the 
case  becomes  very  critical.  Death  is  not  caused  by  excessive  haemorrhage,  but 
by  toxaemia  or  asthenia.  There  is  intense  congestion  of  viscera,  and  the 
haemorrhages  are  believed  to  be  occasioned  by  a  combination  of  altered  blood- 
composition,  impaired  nutrition  of  the  capillary  walls,  and  changes  in  the 
local  vascular  pressure  in  the  various  congested  organs  (Bemiss).  The  hem- 
orrhages usually  bear  a  direct  relation  to  the  intensity  of  the  chill,  which 
favors  internal  congestion. 

III.  The  Asthenic  Type, — In  this  variety  there  are  irregular  neu- 
rotic svmptoms,  restlessness,  and  great  weakness.  The  (;irculation  becomes 
extremely  feeble  and  the  cardiac  sounds  are  scarcely  audible.  The  pulse  is 
reduced  to  a  mere  thread  and  is  intermittent.  In  other  cases  exhausting 
))erspiration  is  a  very  prominent  feature,  which  continues  into  the  remis- 
sion. 

IV.  The  Algid  Type. — The  algid  form  of  pernicious  malarial  fever  sug- 
gests the  algid  stage  of  cholera,  and  is  very  fatal.  There  arc  the  same  prostra- 
ticm  and  collaj)sc,  with  cold  extremities,  cramps,  cyanosis,  dilated  pupils, 
feeble,  husky  voice,  shallow  resj)irati()M,  vomiting,  pm-ging,  and  great  thirst. 
There  are  often  very  profuse  ])ersi)irati(Mi  ami  ollrnsivc  (luid  alviiH>  evacua- 
tions. The  ])iil^c  is  very  feeble  and  invn-nlar.  The  internal  temperature  is 
very   high.     The  intellect  remains  clear. 

In  some  cases  the  disease  resembles  yelhiw  fever,  niul  there  are  profound 


428  MA  LABIA  L    FEVERS. 

jiiuiulice,  serious  neurotic  symptoms,  and  severe  emesis.  The  brain  and  cord 
are  usually  found  ansemic,  dry,  and  firm  (Hertz). 

V.  The  Comatose  Type. — The  comatose  variety  is  rare,  excepting  in 
hot  climates  and  where  the  miasm  is  greatly  concentrated.  The  patient  is 
early  overwhelmed  with  profound  coma,  from  which  it  is  impossible  to  arouse 
him..  He  may  die  suddenly  in  collapse.  The  coma  is  not  necessarily  due  to 
cerebral  congestion  (Bemiss),  although  the  brain  and  meninges  may  both  be 
congested,  but  to  general  toxsemia.  The  surface  of  the  body  is  hot ;  there 
are  elevated  temperature  and  pulse-rate  ;  and  stertorous  breathing  and  jaun- 
dice may  be  present. 

This  variety  of  pernicious  fever  develops  especially  in  |)ersons  who  reside 
in  regions  where  ague  abounds,  and  who  have  neglected  proper  treatment  in 
repeated  attacks.  It  may  be  associated  with  one  of  the  other  graver  forms. 
In  the  United  States  the  congestive  varieties  of  pernicious  ague  are  much 
more  common  than  the  comatose.  Should  the  patient  survive  the  first  attack 
of  coma,  the  second  is  usually  fatal,  but  third  attacks  sometimes  occur. 

In  some  cases,  instead  of  coma,  there  is  sudden,  violent  delirium,  with 
cephalalgia,  congestion  of  the  face,  staring  eyes,  and  great  excitement.  At  the 
autopsy  there  are  found  more  or  less  hypersemia  and  oedema  of  the  brain. 

Complications. — Complications  of  infrequent  occurrence,  but  which  have 
been  from  time  to  time  noted  in  connection  with  the  pernicious  types  of 
malarial  fevers,  are  hemianopsia,  transient  amblyopia,  optic  neuritis,  and 
haemorrhages  (Sulzer),  muscular  contractures  and  choreic  or  ataxic  movements, 
convulsions  (in  children),  local  anaesthesia,  transient  cortical  paralyses,  such  as 
aphasia  with  hemiplegia,  spinal  congestion,  etc. 

It  has  been  suggested,  although  there  is  as  yet  no  proof,  that  some  of  the 
neurotic  symptoms  and  lesions  may  be  due  to  embolic  plugging  of  small 
arterioles  by  the  plasmodium  or  by  pigment-granules.  In  a  case  of  per- 
nicious malarial  fever  with  bulbar  paralysis  Marchiafava  found  the  plasmo- 
dium in  the  nuclei  of  the  facial  and  hypoglossal  nerves,  with  necrosis  of  their 
cells. 

Periodical  delirium  has  exceptionally  been  noted.  In  some  patients  there 
is  a  decided  tendency  to  syncope,  while  others  pass  into  a  condition  of  "sus- 
pended animation,"  in  which  the  radial  pulse  and  respiratory  movements 
almost  disappear,  and  the  cardiac  sounds  are  so  inaudible  that  the  patient 
seems  almost  dead. 

Asthma  sometimes  occurs,  or  there  may  be  severe  and  sudden  localized 
pulmonary  congestion,  with  signs  of  consolidation,  and  sometimes  rusty  spu- 
tum and  dyspnoea  resembling  pneumonia,  but  disappearing  under  the  use  of 
quinine. 

Sequelae. — Repeated  attacks  of  the  severer  forms  of  malarial  fever  leave 
the  patient  in  a  weakened  and  very  irritable  condition.  There  may  be  paral- 
ysis, dropsy,  extreme  anaemia,  or  the  malarial  cachexia.     {Vide  infra.) 

Diag-nosis. — The  different  varieties  of  pernicious  malarial  fever  at  times 
resemble  the  following  diseases,  froni  which  they  are  to  be  diagnosed  :  typhoid 


PEliXICIOUS   INTERMITTENT  FEVER.  429 

fever;  yellow  fever;  cholera;  ulcerative  endocarditis;  pysemia  and  septicfemia; 
urtemia  and  meningitis. 

Typhoid  Fever. — Simple  remittent  and  j)ernicious  malarial  fever  are  dis- 
tinguished from  typhoid  fever  by  the  absence  of  the  rose-colored  rash,  epistaxis, 
tympanites,  and  pea-soup  evacuations  which  so  frequently  occur  in  the  latter 
disease.  Moreover,  in  typhoid  fever  the  invasion  is  slower,  and  usually  with- 
out distinct  chill ;  the  fever  is  more  continuously  high  after  reaching  a  maxi- 
mum than  in  remittent  fever;  and  the  delirium,  carj)hal()gia,  subsultus,  and 
other  neurotic  or  ataxic  symptoms  tire  more  pronounced.  The  tongue  in 
typhoid  fever  is  red  and  small  at  first,  afterward  brown  and  dry.  In  malarial 
fevers  it  is  large  and  more  heavily  coated.  In  severe  malarial  fevers  there  is 
often  a  history  of  one  or  more  previous  paroxysms  and  of  exposure  to  infec- 
tion, and  the  gastric  symptoms  are  more  pronounced  at  the  onset.  There  is 
also  a  tendency  to  become  jaundiced  which  is  absent  in  typhoid  fever,  and  the 
skin  is  sallow  at  the  commencement  of  the  disease.  The  symjUoms  of  gastric 
irritation  appear  earlier,  and  are  more  pronounced,  than  in  typhoid  fever.  The 
face  during  the  j)aroxysm  is  more  flushed,  the  eyes  are  congested,  and  the  ex- 
pression is  more  animated  than  in  typhoid  fever. 

The  detection  of  typhoid  bacilli  in  the  stools  would  render  the  diagnosis  cer- 
tain, but  their  demonstration  is  difficult. 

Yellow  Fever. — In  remittent  fever  typical  black  vomit  never  occurs,  as  it 
may  in  yellow  fever ;  the  pulse  is  more  firm  ;  the  temj)eratui'G  is  higher ;  and 
the  influence  of  quinine  and  the  subsequent  course  of  the  disease  are  to  be 
noted.  The  icteric  foi'm  of  pernicious  ague  affects  those  who  have  been  long 
resident  in  an  ague  district,  but  yellow  fever  selects  particularly  the  recent 
arrivals.  The  jaundice  appears  later  in  the  course  of  yellow  fever.  In  per- 
nicious ague  free  pigment  should  be  sought  in  the  blood.  Yellow  fever  is  apt 
to  be  more  quickly  fatal. 

Cholera. — The  algid  form  of  pernicious  ague  is  to  be  distinguished  from 
<'holera  by  the  free  pigment  in  the  blood,  and  tlie  fact  that  the  copious  watery 
evacuations  are  often  ])receded  by  bloody  stools,  which  is  not  the  case  in 
cholera.  In  cholera  there  is  the  presence  of  an  epidemic  and  the  history 
of  infection. 

Ulcerative  Endocarditis  and  Pyaemia. — Remittent  and  pernicious  malarial 
fever  may  resemble  acute  ulcerative  endocarditis  or  pyjcmia  and  septicaemia. 
In  the  former  the  physical  examination  of  the  heart  and  the  presence  of  embolic 
infarctions  will  aid  in  establishing  the  diagnosis,  and  in  the  latter  the  diagnosis 
can  be  made  by  the  exclusion  of  a  source  of  septic  infection  and  by  the  greater 
regularity  of  the  paroxysms  occiu'ring  in  pernicious  fever. 

Uraemia  and  Mrninr/ifis. — The  comatose  form  of  pernicious  fever  nnist  be 
distinguished  from  uraM)iia  and  meningitis.  The  presence  of  free  pigment- 
granules  in  the  blood  and  tiie  enlarged  sj)leeu  are  to  be  noted,  with  a  history 
of  ])rcvious  malarial  jiaroxysms.  In  meningitis  the  case  is  of  longer  duration 
before  coma  aj)j)ears ;  it  is  ])rece(led  by  |tliotophobia  and  delirium,  and  the 
temperature  is  lower  than   in  comatose  ague. 


430  MALARIAL    FEVERS. 

Mortality. — In  the  rural  parts  of  the  Southern  Atlantic  States  the  num- 
ber of  fatal  oases  of  malarial  fevers  is  70.6  in  every  1000  deaths.  In  cities 
the  number  is  11.5  (Johnston). 

Treatment. — The  treatment  of  pernicious  malarial  fevers  demands  the 
utmost  care  and  promptness.  Quinine  must  be  given  at  once  by  hypodermic 
injection  in  doses  of  fifteen  grains  in  distilled  water,  using  a  soluble  salt,  such  as 
the  tannate,  hydrochlorate,  or  hydrobromate,  combined  with  a  grain  of  sodium 
chloride  (Bocelli).  The  sulphate  and  bisulphate,  which  are  the  preparations 
most  frequently  employed  when  quinine  is  given  by  the  mouth,  are  not 
adapted  for  hypodermic  use  on  account  of  the  difficulty  of  dissolving  them 
in  a  small  bulk  of  water  without  the  use  of  acids,  and  the  consequent  liabil- 
ity to  abscesses  at  the  site  of  injection.  Free  stimulation  by  the  mouth,  rec- 
tum, or  subcutaneously  must  be  employed.  Everything  depends  upon  tid- 
ing the  patient  over  a  present  paroxysm  and  preventing  the  recurrence  of  o. 
second,  which  is  so  apt  to  be  fatal.  The  patient  must  be  kept  absolutely 
quiet.  Opium  in  full  doses,  given  early,  is  often  serviceable.  Morphine  and 
atropine  may  be  given  with  whiskey  or  brandy,  and  diffusible  heart  stimulants, 
such  as  chloroform  or  ammonia,  are  required  when  there  is  any  evidence  of 
enfeebled  circulation.  Hypodermic  injections  of  strychnine  are  also  service- 
able.    Warm  alcoholic  stimulants  should   be  given  by  the  rectum. 

Hot  bottles  should  be  applied  to  the  surface  for  the  collapse,  while  vigor- 
ous rectal  and  Ivypodermic  stimulation  is  maintained.  By  stimulating  and 
nourishing  such  cases  even  the  worst  of  them  are  rendered  not  necessarily 
fatal,  and  everything  depends  upon  careful  attention  to  all  the  details  of  the 
treatment.  In  the  violently  congestive  type,  with  delirium  and  a  full  pulse, 
venesection  has  been  employed  ;  but  it  is  of  doubtful  efficacy,  for  the  patient 
is  soon  in  greater  need  of  stimulation  than  depletion.  Saline  laxatives,  cold 
sponging,  cold  applications  to  the  head,  and  sedatives,  especially  opium,  are 
indicated  for  this  type  of  fever. 

Vomiting  and  purging  must  be  controlled  by  opium.  Warburg's  tincture 
may  be  given  in  the  intermission  or  remission,  but  cinchonism  must  be  steadily 
maintained.  Patients  have  become  both  blind  and  deaf  under  the  excessive 
use  of  quinine  in  these  cases,  but  fortunately  such  results  are  almost  invari- 
ably temporary  accidents,  and  the  patient's  life  depends  upon  the  prevention 
of  another  paroxysm  through  the  agency  of  this  invaluable  specific. 

In  the  haemorrhagic  form  the  vomiting  may  be  controlled  by  morphine, 
and  very  mild  diuretics  and  diaphoretics  are  serviceable.  Ergot  and  turpen- 
tine have  been  given  with  the  idea  of  checking  the  haemorrhages,  but  such 
remedies  are  of  very  doubtful  efficacy. 

With  signs  of  improvement  the  patient's  strength  must  be  supported  by  a 
nourishing  and  concentrated  fluid  diet  and  nutrient  enemata.  Beef  juice, 
beef  peptonoids,  egg-albumin  in  sherry,  and  milk  should  be  given  in  small 
quantities  repeated  every  hour  or  two.  As  convalescence  advances,  tonics, 
such  as  simple  bitters,  iron,  quinine,  and  hypophosphites,  will  be  required  to 
build  up  the  impoverished  blood  and  restore  the  greatly  reduced  system. 


PEBXICIOT'S    REMITTENT.— TYPHO-MALARIAL.  431 

IV.  Pernicious  Remittent  Fever. 

This  type  corre.sponds  .so  nearly  with  perniciou.s  intermittent  fever,  except- 
ing in  regard  to  the  temperature-curve,  that  a  separate  description  is  super- 
fluous.    The  fever  is  sometimes  called  African  fever,  jungle  fever,  etc. 

None  of  the  .severe  types  of  ague  correspond  as  closely  in  regard  to  the 
time  and  duration  of  the  paroxysms  as  do  the  simple  forms  of  paludal 
fever,  and  it  is  therefore  less  easy  to  separate  them  with  distinctness.  When 
death  occurs  early  in  the  disease  it  is  difficult  to  ascertain  whether  the  type 
were  intermittent  or  remittent. 

V.   Typho-malarial  Fever. 

The  name  typho-malarial  fever  must  not  imply  a  specific  disease,  but  rather 
a  combination  or  coexi.stence  of  the  two  diseases,  typhoid  fever  and  malarial 
fever,  in  the  same  individual.  It  is  at  best  a  misleading  term,  and  ought  to 
be  abandoned.  Nevertheless,  the  name  has  entered  medical  literature  exten- 
sively, and  it  is  still  in  common  use  in  a  large  .section  of  this  country. 

Typho-malarial  fever  should  not  be  confounded  with  the  ''  typhoid  condi- 
tion "  which  may  supervene  in  protracted  and  severe  remittent  fever. 

Etiology. — Typho-malarial  fever  may  occur  in  malarious  regions  where 
men  are  crowded  in  camps  or  prisons  under  bad  hygienic  conditions  and  with 
a  water-supply  contaminated  with  sewage.  For  this  reason  it  is  sometimes 
called  "  camp  fever."  In  the  United  States  this  fever  occurs  chiefly  in  the 
autumn  and  in  the  Southern  Atlantic  and  Gulf  States.  To  produce  the  fever 
there  mu.st  be  a  double  infection  with  the  typhoid  bacillus  and  the  malarial 
Plasmodium.  Unfortunately,  positive  evidence  that  these  two  germs  can  co- 
exist in  the  same  individual  has  not  yet  been  obtained,  since  the  natural  his- 
tory of  both  germs  has  been  studied  for  only  a  brief  cfecade.  Autopsies,  too, 
are  infrequent,  for  many  of  the  patients  recover,  and  hence  the  description  of 
the  double  disea.se  is  based  solely  upon  clinical  features.  In  1888,  Johnston' 
published  an  exhaustive  paper  containing  researches  on  the  question  of  the 
separate  existence  of  a  tyi)h()-malarial  fever.  The  paper  was  ba.sed  upon 
answers  received  from  three  hundred  and  fifty  physicians  living  along  the 
Atlantic  and  Gulf  coa.sts  of  the  United  States  and  in  other  malarial  regions, 
and  their  belief  was  about  evenly  divided  as  to  the  existence  and  non-existence 
of  the  disease  in  question  as  an  inde})endent  fever. 

Accumulating  evidence  is  very  convincing  that  the  majority  of  cases 
reportod  as  typho-malarial  fever  arc  simply  modified  or  irregular  forms  of 
ty|)hoid  fever,  without  any  malarial  admixture.  Whatever  view  is  taken, 
however,  of  the  etiology  of  .so-called  typho-malarial  fever,  it  is  an  imdoubted 
fart  that  in  a  malarious  region  a  number  of  cases  occur  from  time  to  time 
which  present,  from  a  clinical  standpoint,  the  features  of  both  di.seases  in 
combination.     These  .symptoms  are  as   follows  : 

Symptomatology. — Theon.set  is  often  more  abrupt  than  in  typhoid  fever. 
There  are  one  or  more  .severe  chills,  and  the  temi)erature  ri.<es  suddenly,  and 
*  Tramaci.  Asaoc.  Avi.  Phynidam,  vol.  iii.,  1888,  p.  20,  et  acq. 


432 


MALARIAL    FEVERS. 


not  gradually  as  in  enteric  fever.  As  in  typhoid  fever,  there  are  frontal  head- 
ache, epistaxis,  sometimes  a  rose-colored  eruption  of  maculae  upon  the  abdomen 
and  lower  chest  or  back,  tympanites,  low  muttering  delirium,  subsultus,  diar- 
rhoea. If  the  disease  commences  with  the  typical  temperature  of  typhoid 
fever,  rising  slowly  during  the  first  week  and  maintaining  a  fairly  uniform 
maximum  for  the  next  week  or  ten  daj'S,  it  is  soon  broken  by  decided  remis- 
sions of  from  two  to  four  degrees  which  recur  at  regular  intervals.  If  the 
malarial  type  predominate,  there  may  be  decided  chills,  with  a  maximum 
temperature  of  106.5°  F.  and  sweating,  and  the  remissions  are  very  marked. 
The  spleen  is  much  more  enlarged  than  it  often  is  in  enteric  fever,  and 
there  is  more  severe  gastro-intestinal  disturbance,  with  vomiting  of  bile, 
jaundice,  and  hepatic  congestion.  There  frequently  are  severe  pains  in  the 
back  and  extremities.  As  a  rule,  the  typhoid  symptoms  predominate  in 
other  respects  than  the  invasion  and  the  temperature,  but,  contrary  to  expecta- 
tion, the  supposed  union  of  the  two  diseases  does  not  appear  to  be  as  fatal  as 
enteric  fever  occurring  uncomplicated.  According  to  Woodward,  it  is  less  fatal 
in  the  })roportion  of  about  1  to  4. 

Treatment. — The  treatment  is  a  combination  of  the  treatment  employed 
in  both  diseases.  Quinine  must  be  given  as  in  remittent  fever.  If  the  fever 
l)e  high,  cold  sponge-baths,  or  if  the  patient  be  sufficiently  robust  cold  tub-baths, 
may  be  given,  with  a  fluid  diet  and  stimulants.  The  stools  must  be  carefully 
disinfected,  and  complications  are  to  be  met  as  in  the  case  of  simple  typhoid 
fever.  For  further  details  the  reader  is  referred  to  the  article  upon  Typhoid 
Fever. 


VI.  Malarial  Cachexia,  or  "  Chronic  Malaria." 
This  condition  may  occur  as  a  result  of  repeated  attacks  of  intermittent  or 
of  remittent  fever,  or  it  may  originate  in  persons  living  in  a  malarious  locality 
who  have  never  had  the  paroxysmal  fever  in  any  form.  It  is  more  apt  to 
occur  among  the  older  residents  of  an  ague  region  than  among  new-comers. 
The  condition  is  quite  typical.  The  face  is  pale,  and  the  skin  has  a  muddy  or 
yellowish  hue.  There  may  be  slight  jaundice.  There  is  decided  anaemia, 
with  attendant  disordered  digestion.  The  spleen  is  melanotic  and  enlarged, 
and  may  be  distinctly  felt  by  abdominal  palpation.  It  may  even  extend  as 
far  as  the  umbilicus.  The  tongue  is  large,  pale,  flabby,  and  covered  with 
a  thick  white  coating,  giving  a  bad  taste  and  a  bad  breath.  The  thin  margins 
are  often  indented  by  the  teeth.  There  is  more  or  less  gastric  indigestion, 
and  the  bowels  are  sometimes  constipated  or  sometimes  diarrhoea  exists.  The 
circulation  is  inactive,  and  the  hands  and  feet  are  cold.  There  are  dulness, 
more  or  less  mental  depression,  and   lassitude. 

In  bad  cases  there  may  be  dropsy  or  general  anasarca,  or  a  scorbutic  con- 
dition may  develoji,  with  epistaxis,  ecchymoses,  etc.  The  temperature  is  not 
infrequently  subnormal  or  there  may  be  slight  fever  of  an  irregular  type. 
The  liver  may  be  enlarged  and  melanotic,  like  the  spleen. 


MALARIAL    CACHEXIA,    OB    '' CHRONIC  MALARIA:'      4:« 

In  obscure  cases  the  detection  of  the  crescentic  forms  of  tlie  midarial  germ 
and  of  flagelloe  in  the  blood  is  of  great  vahie  in  diagnosis  (Osier). 

Secondary  diseases,  such  as  dysentery  or  tuberculosis,  may  attack  cachectic 
patients,  in  whom  they  are  very  apt  to  become  fatal.  While  remaining  in  a 
malarious  region  the  cachectic  are  always  more  or  less  liable  to  have  a  sudden 
seizure  of  ague  in  a  pernicious  form. 

Treatment. — The  condition  of  malarial  cachexia  requires  tonic  and 
hygienic  treatment.  Such  cases  are  quite  aufemic,  and  iron,  arsenic,  and 
cod-liver  oil  are  indicated.  There  may  be  constipation,  which  should  be 
relieved  by  regulation  of  the  diet  and  laxatives.  Cascara  or  a  pill  of  aloin 
gr.  A^,  belladonna  gr.  -^,  and  podophyllin  gr.  -^q,  may  be  given  at  night 
for  the  constipation,  and  an  occasional  ten-grain  dose  of  calomel  is  beneficiah 
Many  cachetic  patients  make  very  slow  progress  while  remaining  in  a  malarial 
district,  but  improve  as  soon  as  they  begin  to  travel,  and  in  very  obstinate  cases 
change  of  locality  is  the  only  measure  that  is  eifectual  in  producing  a  cure. 

The  spleen  is  often  greatly  enlarged,  and  for  this  condition  ergot  is  some- 
times given  internally,  and  the  ointment  of  the  biniodide  of  mercury  or  a 
belladonna  plaster  may  be  applied  locally.  General  tonic  treatment  seems  to 
be  more  efficacious  than  any  local  treatment  designed  to  reduce  the  size  of  the 
spleen. 

Vol.  I.— 28 


CHOLERA. 

By  W.  oilman  THOMPSON. 


Definition. — Cholera  is  an  acute  infectious  disease,  occurring  both  endemi- 
cally  and  as  an  epidemic,  and  characterized  by  violent  vomiting,  purging  with 
serous  stools,  and  by  collapse.  It  is  caused  by  a  bacillus,  and  it  has  been 
recently  defined  as  a  "  specific  intestinal  putrefaction,  with  the  production  of  a 
specific  toxine."  ^ 

Synonyms. — Cholera  algida  ;  Cholera  Asiatica  ;  Cholera  maligna  ;  Cholera 
infectiosa ;  Epidemic  cholera. 

"Cholerine"  is  a  misleading  name  which  is  applied  either  to  very  mild 
cases  of  true  cholera,  in  which  the  collapse  and  later  typhoid  symptoms  are 
absent,  or  the  word  is  used  to  designate  severe  and  often  fatal  cases  of  diar- 
rhoea accompanying  a  cholera  epidemic.  The  former  usage  is  German,  the 
latter  French. 

Recent  Epidemics. — Cholera  originated  in  India,  in  which  country  alone 
it  is  endemic.  It  has  been  definitely  described  since  the  tenth  century,  although 
it  was  doubtless  known  long  before.  The  invasion  of  India  by  various  foreign 
powers  served  to  extend  the  limits  of  the  disease,  and  to-day  the  enormous  relig- 
ious Eastern  pilgrimages  are  the  chief  means  of  spreading  the  contagion.  In 
the  sacred  cities  of  Mecca  and  Medina,  where  these  pilgrimages  are  made, 
sanitation  is  quite  unknown,  and  cholera  frequently  becomes  epidemic.  In 
Mecca  150,000  sheep  are  annually  slaughtered  for  ceremonial  rites,  and  the 
waste  portions  of  the  animals  rot  in  the  sun  and  favor  the  development  of 
fevers,  dysentery,  and  cholera. 

For  centuries  frequent  epidemics  of  cholera  have  occurred  in  India,  Persia, 
Mesopotamia,  Egypt,  and  in  Russian  provinces  bordering  on  the  Black  and 
Caspian  Seas.  The  sacred  city  of  Hundwar  is  the  great  focus  from  which 
cholera  radiates  throughout  India,  and  Alexandria  is  a  focus  for  the  propa- 
gation of  European  epidemics. 

In  Bengal  the  habits  of  the  natives  in  regard  to  bathing  and  washing  their 
utensils  in  filthy  water,  and  storing  water  for  a  long  time  in  unprotected  tanks, 
greatly  favor  the  extension  of  cholera  epidemics. 

Cholera  first  ai)])eared  in  Europe  in  1832,  when  there  were  120,000  victims 
in  France.  In  the  same  year  it  was  imported  in  an  emigrant  vessel  to  North 
America,  and  the  first  case  ap])eared  at  Quebec,  whence  it  spread  to  New  York 
and  elsewhere  through  the  United  States.     In  New  York  City  3500  died. 

'  Report  on  Cholera  in  Europe  and  India,  1890,  Edward  O.  Shakespeare,  M.  D.,  United  States 
Cholera  Commissioner. 

4;'.4 


CHOLERA.  435 

Eighteen  years  later  the  disease  \vas  again  introdnced — at  New  Orleans  from 
abroad.  It  extended  rapidly,  and  in  the  ensning  year  there  were  5000  deaths 
in  New  York.  Five  years  later,  in  1854,  it  again  developed  in  that  city,  caus- 
ing 2000  deaths.  It  last  visited  the  United  States  as  an  epidemic  in  1873. 
It  then  ocenrrecl  simultaneously  at  several  remote  localities  where  it  had  been 
conveyed  by  immigrants.  In  the  United  States  the  epidemics  of  late  years 
have  become  gradually  milder. 

During  the  period  between  1884  and  1887  cholera  appeared  at  various 
points  in  Europe,  and  finally  reached  Paris,  but  it  was  kept  out  of  England 
by  improved  sanitation.  In  1883  another  severe  epidemic  occurred  in  Egypt, 
in  which  there  were  50,000  deaths,  and  over  600  natives  died  daily  in  Cairo 
alone  (Parke).  In  1886-87  an  epidemic  of  cholera  in  Chili  caused  over 
22,000  deaths.  In  1890  epidemics  of  cholera  occurred  in  Natal,  Corea, 
Japan,  India,  Italy,  Spain,  and  Asiatic  Turkey.  In  Abyssinia  4000  deaths 
from  cholera  took  place  in  a  fortnight  during  September,  1890. 

During  the  early  summer  of  1892  a  severe  cholera  epidemic  originated  in 
Meshed  in  Persia,  and  extended  to  Russia  by  way  of  the  Trans-caucasus  rail- 
road. At  the  present  time  (August,  1892)  it  has  invaded  Nijni -Novgorod, 
]\Ioscow,  and  St.  Petersburg,  and  has  been  carried  to  Hamburg  and  Havre, 
The  epidemic  is  also  advancing  along  the  borders  of  the  Black  Sea.  Mean- 
while many  deaths  from  "cholerine"  have  occurred  in  the  environs  of 
Pari>. 

Etiology. — Predisposing  causes  are  privation,  famine,  debauchery,  fatigue, 
debilitating  diseases,  alcoholism,  mental  distress,  eating  decom])osing  meat  or 
spoiled  fruit,  drinking  unwholesome  water.  These  are  merely  the  common 
causes  which  favor  the  spread  of  any  infectious  or  contagious  disease,  and 
beyond  this  ftict  they  have  no  s})ecial  influence  upon  the  spread  of  cholera, 
except  in  the  case  of  unwholesome  food  and  water,  which,  in  addition  to  dis- 
ordering the  digestion,  may  convey  the  cholera  germs. 

Cholera  has  never  been  known  to  spread  more  rapidly  than  the  ordinary 
rate  of  human  travel  by  land  or  sea,  and  it  is  essentially  a  disease  of  densely 
populated  districts.  It  advances  along  the  seacoast  from  town  to  town,  fol- 
lows the  lines  of  traffic  by  land  and  along  great  rivers,  and  lingers  in  crowded 
cities  and  encampments.  The  infectious  principle  is  conveyed  by  ships,  in 
foul  water,  soiled  clothing,  filth  of  any  kind,  vehicles,  baggage,  etc.  It  has 
been  carried  by  a  box  of  clothing  from  Euroi)e  to  the  Mississippi  Valley.  It 
is  possible  that  flies  serve  as  carriers  of  some  of  the  contagion,  and  it  is  there- 
fore well  to  protect  food  from  them  and  to  keep  them  from  access  to 
excrement. 

Climate  and  Hea-son.— It  is  now  generally  believed  that  cholera  is  not  ]>rop- 
agated  through  the  atmosphere,  but  to  aid  its  extension  the  locality  and  season 
must  be  favorable,  for  alterations  in  its  intensity  are  eflected  by  certain  meteor- 
ological changes.  Its  spread  is  not  affected,  however,  by  prevailing  winds,  as 
it  would  be  if  the  germ  were  l)onie  through  the  atmosphere. 

Cholera  has  been  known  to  occur  in  all   climates  exeepfing  the  arctic,  and 


436  CHOLERA. 

at  all  seasons,  but  as  a  rule  its  progress  is  arrested  completely  by  cold,  while  a 
warm,  moist  season  favors  it.  In  a  given  locality  an  epidemic  may  cease  with 
the  onset  of  winter,  only  to  be  revived  in  the  spring. 

Age  and  Sex. — The  disease  is  of  commonest  oectn-rence  between  twenty- 
five  and  fifty  years  of  age.  It  may  occur  in  childhood,  and  it  is  rare  in 
old  age.     Cholera  attacks  males  somewhat  more  frequently  than  females. 

Jiace. — In  India,  Hindus  and  Mohammedans  are  more  susceptible  to 
cholera  than  are  Europeans,  but  this  is  no  doubt  due  in  great  part  to  differ- 
ences in  hygienic  surroundings  rather  than  to  race  influence. 

Social  Position. — Cholera  is  essentially  a  filth  disease,  and  is  therefore  com- 
moner in  the  lower  strata  of  society,  among  the  very  poor  and  ignorant.  Its 
chief  victims  are  found  in  the  slums  and  dirty  tenements  of  the  over-pop- 
ulated quarters  of  large  cities.  Those  who  are  convalescing  from  other  diseases 
are  liable  to  be  attacked  by  cholera.  Thus  at  Helonan,  near  Cairo,  in  1883, 
9.34  per  cent,  of  such  cases  were  afflicted,  but  only  2,63  per  cent,  of  the  pre- 
viously healthy  were  seized  (Parke). 

The  agent  which  causes  the  disease  is  capable  of  very  rapid  increase,  both 
within  the  body  and  apart  from  it,  and  it  is  discharged  from  the  body  in  the 
stools.  The  evacuations  of  preliminary  choleraic  diarrhoea,  as  well  as  the  cha- 
racteristic serous  stools,  are  highly  infectious.  The  cholera  bacillus  undoubt- 
edly enters  the  system  through  the  medium  of  contaminated  food  and  drink, 
especially  the  latter. 

The  extension  of  cholera  is  so  far  controllable  by  proper  drainage  and  san- 
itation that  if  ideal  hygienic  measures  could  be  realized,  quarantine  would  be 
unnecessary  and  the  disease  might  be  almost  exterminated. 

In  Calcutta  the  spread  of  epidemics  has  been  greatly  diminished  of  late 
years  by  a  more  copious  supply  of  water  to  the  city. 

Physicians,  nurses,  and  others  in  attendance  upon  cholera  patients  are  not 
especially  liable  to  be  attacked  by  the  disease,  provided  that  they  are  not  over- 
worked and  that  they  take  proper  precautions.  They  are,  however,  by  no 
means  exempt,  and  many  cases  are  recorded  where  the  disease  has  been  trans- 
mitted by  direct  contagion.  Nurses  are  more  apt  to  be  attacked  than  physi- 
cians, because  they  are  constantly  with  the  patients  and  have  to  remove  the 
evacuations.  When  patients,  debilitated  by  other  diseases,  have  been  allowed 
to  remain  in  wards  with  cholera  patients,  inhaling  the  emanations  from  their 
evacuations,  they  liave  been  frequently  attacked  by  the  disease.  Those  who 
wash  the  soiled  clothing  of  cholera  patients  are  often  seized,  proving  that 
the  disease  can  be  conveyed  by  fomites.  It  has  been  communicated  through 
the  medium  of  the  mails. 

The  Cholera  Bacillus. — Animals  were  at  first  thought  to  be  immune  to 
cholera,  but  recent  careful  experiments  upon  dogs  and  guinea-pigs  have  proven 
the  contrary,  and  the  disease  has  been  demonstrated  in  them  after  inoculation 
(Pasteur). 

Koch,'  in  1884.  was  the  first  to  describe  a  distinct  bacillus  associated  with 

'  Berliner  klinische  Wochenschrift,  Marcli  31,  1884. 


ETIOLOGY.  437 

cholera.     In  1885  he  announced  that  he  coiihl   reproduce  cliolera  in  guinea- 
pigs  without  making  the  inoculations  directly  into  the  intestine. 

It  is  believed  that,  whether  inhaled  in  the  mouth  or  swallowed  with  food 
or  drink,  the  germ  must  always  tirst  reach 
the  intestine  by  way  of  the  stomach  before 
becoming  active,  and  that  the  alkaline  intes- 
tinal contents  constitute  its   most  favorable 

habitat.     It  is  found  most  abundantly  in  the  !( ,\  T',' i^ /j''  t    '-T. '.'   ..---tt 

ileum,  on  its  surface,  and  within  the  tubides 
of  the  mucous  glands.  The  bacillus  which 
was  discovered  by  Koch  in  the  stools  of 
cholera  patients  presents  the  following  cha- 
racteristics:  It  is  from  one-half  to  two-thirds  ^ 
the  size  of  the  tubercle  bacillus,  but  thicker 

and  somewhat  curved,  reseml)hng  a  crescent,       i  I'V-'j^''    '^  /'''-*  /'  ;  ''fij 
comma,  or  half  circle,  or  a  double  curve  like         i  J^""    Ji     I j  \\i'/ ill  ' 
an  S.  (See  Fig.  28).    When  freshly  obtained       /         '^   j/   7  /V 
from   the  stools  the   length  of  the   bacillus  ^  u     ^ «     li      ^  r^-^  ■,      ,v    x.s 

^  Comma-shaped  Bacillus  of  Cholera  (Koch). 

seldom   exceeds  1//,  and  many  are  only  .5/i 

long.     The  germs  are  frequently  aggregated  in  small  groups   or  arranged  in 

spirals,  when  they  resemble  the  genus  Spirillum. 

The  bacillus  grows  rapidly  in  and  upon  various  culture  media.  It  thrives 
in  alkaline  nitrogenous  media,  such  as  milk,  meat  juice,  or  peptone,  and  it 
grows  well  in  a  slightly  alkaline  gelatin,  which  it  causes  to  liquefy.  It  also 
grows  upon  solid  substances,  such  as  potatoes,  damp  dirty  linen,  and  moist 
earth.  A  decided  acid  reaction  of  the  culture  medium  stops  its  reproduction  ; 
hence  it  develops  in  the  intestine,  and  not  in  the  .stomach.  It  is  destroyed  by 
drying  for  a  short  time  and  by  a  temperature  of  143°  F.  (Sternberg),  but  not 
by  freezing  to  even  — 10°  C.  It  exhibits  one  or  two  cilia  at  one  end,  and  is 
actively  motile  in  the  fluids  in  which  it  grows.  It  reproduces  by  fission  with 
enormous  rapidity,  and  spores  have  not  been  identified  with  it.  The  bacillus 
thrives  in  foul  water,  especially  briny  water,  and  Koch  considers  the  Delta  of 
the  GanMS  to  be  its  natural  home.  This  bacillus  is  so  constantly  associated 
with  cholera  stools,  and  so  constantly  found  in  the  intestines  of  those  dying 
of  cholera,  that  it  may  be  regarded  as  causative  as  well  as  pathognomonic  of 
tiie  disease. 

According  to  Klein  and  Gibbes,  who  investigated  the  cholera  in  India  on 
behalf  of  the  British  government,  there  are  several  allied  species  of  the  bacil- 
lus, which  difi'cr  in  their  size,  mode  of  growth,  and  effect  on  the  lower 
animals. 

Bacilli  which  closely  resemble  the  cholera  bacillus  in  appearance  have  been 
foiuid  ill  the  saliva  and  in  some  healthy  stools,  and  in  the  al vine  discharges  of 
dinrrhfea  and  dysentery;  hence  tin;  cholera  bacillus  may  be  overlooked,  for, 
while  it  only  occurs  in  Asiatic  cholera,  it  is  not  |)resent  when  the  stools  become 
normal,  or  even   in   the  diarrhcca  of  convalescence.     At  the  latest,  it  is  to  be 


438  CHOLERA. 

detected  ten  davs  after  the  commencement  of  an  attack,  and  it  often  disappears 
by  the  fourth  day  of  the  disease.  It  is  apparently  shorter-lived  than  many 
bacilli.  To  facilitate  its  detection  cultures  should  be  made  from  the  stools  and 
frequently  repeated  in  order  to  keep  the  germs  alive  for  any  length  of  time. 

Microscopic  examination  alone  does  not  establish  its  identity,  but  it  may  be 
cultivated  and  inoculated  in  the  lower  animals,  and  through  such  inoculation, 
together  with  its  behavior  in  the  various  nitrogenous  culture  media,  it  is  pos- 
sible to  demonstrate  that  the  germ  is  typical.  Since  the  germ  multiplies  rap- 
idly in  the  intestine  (which  contains  little  or  no  free  oxygen),  it  follows  that  it 
is  anaerobic ;  but  it  has  been  proved  that  immediately  after  leaving  the  intes- 
tine it  is  more  easily  destroyed  by  various  agents,  such  as  the  acid  of  the  gas- 
tric juice,  than  after  it  has  been  exposed  to  the  air  for  some  time,  when  it 
Ijecomes  aerobic.  Hence  the  practical  importance  of  the  immediate  disinfection 
of  all  choleraic  discharges  as  soon  as  they  are  voided. 

As  is  the  case  with  several  other  infectious  diseases,  when  a  warm,  dry  sea- 
son closely  follows  a  very  wet  one  cholera  becomes  more  active  and  virulent. 
This  is  explained  by  the  fact  that  such  conditions  promote  putrefaction  and 
fermentation  and  furnish  favorable  products  on  which  the  germs  thrive.  It 
needs  but  the  access  of  a  few  germs  to  such  a  soil  to  soon  contaminate  a  very 
extensive  area. 

The  facts  which  support  the  belief  in  the  bacillus  of  Koch  as  the  cause  of 
cholera  are  as  follows  : 

I.  It  is  the  almost  invariable  accompaniment  of  the  stage  of  collapse. 

II.  It  is  not  found  apart  from  the  disease,  and  disappears  with  it. 

III.  It  occurs  in  the  stools  and  in  the  small  intestine,  which  is  the  region 
particularly  affected  by  the  disease. 

IV.  When  inoculated  in  certain  of  the  lower  animals  it  produces  symptoms 
similar  to  those  of  cholera,  with  collapse  and  death. 

Since  the  germs  are  not  found  in  the  tissues  generally  throughout  the  body, 
it  seems  probable  that  they  produce  a  poisonous  substance,  a  toxalbumin,  or 
])tomaine  in  the  intestine,  which,  on  being  absorbed,  occasions  the  constitu- 
tional symptoms  of  the  disease.  Similar  action  has  been  clearly  demonstrated 
in  enteric  fever  and  diphtheria.  Ptomaines  and  toxines  have  been  isolated 
from  cultures  of  cholera  germs,  which,  injected  into  animals,  cause  fever, 
cramps,  diarrhoea,  and  collapse. 

Gamaleia  and  Lowenthal  have  succeeded  in  rendering  certain  animals 
immune  to  cholera  by  the  use  of  attenuated  cultures. 

The  following  is  a  summary  of  the  present  beliefs  in  regard  to  the  nature 
of  cholera  which  have  been  discussed  in  the  previous. pages  ; 

Tiie  disease  is  due  to  a  specific  virus — namely,  a  germ  which  enters  the 
body  through  the  alimentary  canal  and  attacks  the  small  intestine,  where  it 
develops  ptomaines,  which  on  being  absorbed  into  the  system  produce  consti- 
tutional symptoms.  The  disease  is  propagated  by  fomites  and  by  direct  con- 
tact with  the  stools.  The  chief  ay-ent  for  its  dissemination  is  contaminated 
drinking-water.     The  contagion  multiplies  with  extreme  rapidity  both  inside 


MOB  BID    ANATOMY.  439 

and  outside  of  tho  body,  and  it  thrives  especially  in  warm,  moist  putrefactive 
organic  matter. 

Morbid  Anatomy. — The  local  action  of  the  morbific  agent  of  cholera  is 
chiefly  directed  against  the  epithelia  and  subjacent  tissues  of  the  small  intes- 
tine, especially  its  lower  end.  The  general  or  constitutional  ^esions  are  not 
distinctive.  They  are  produced  through  the  influence  of  poisonous  material 
absorbed  from  the  intestine  which  chiefly  affects  the  vaso-motor  centres  and 
other  parts  of  the  nervous  system. 

In  an  autopsy  made  half  an  hour  after  death  in  a  typical  case  of  cholera 
Milles  noted  the  following  appearances  :  The  small  intestine  was  of  a  rose-red 
color,  and  distended  as  if  paralyzed.  It  contained  a  typical  clear  stool.  The 
mucous  membrane  was  swollen  and  denuded  of  its  epithelium.  The  follicles 
were  filled  with  epithelial  detritus  and  comma  bacilli,  and  their  orifices 
appeared  as  red  spots.  Comma  bacilli  were  also  discovered  in  the  subepithe- 
lial tissue,  to  which  they  are  supposed  to  penetrate  by  their  own  activity. 

In  those  cases  in  which  death  occurs  very  early  in  the  course  of  the  disease 
there  are  no  pathological  changes.  Rigor  mortis  appears  early,  and  lasts  during 
a  longer  period  than  usual.  There  may  be  post-mortem  spasmodic  muscular 
twitchings,  lasting  for  two  or  three  hours.  In  typical  cases  there  is  dryness  of 
all  the  tissues,  including  the  muscles,  connective  tissues,  and  skin.  As  a 
result,  decomposition  proceeds  very  slowly.  The  serous  outpouring  in  the 
intestine  must  be  regarded  as  a  simple  transudation,  rather  than  as  the  result 
of  a  true  inflammatory  process. 

In  typical  cases  the  mucous  membrane  of  the  small  intestine,  especially  the 
ileum,  is  congested  or  soft  and  oedematous,  and  it  is  frequently  the  seat  of 
ecchymoses.  The  villi  are  swollen,  stripped  of  epithelium,  and  the  blood- 
disks  in  their  capillaries  are  destroyed  and  free  pigment  is  found  (Sutton). 
The  congestion  may  extend  over  a  large  part  of  the  intestine,  or  it  may  nearly 
surround  the  swollen  agminated  or  solitary  glands.  There  is  sometimes  croup- 
ous inflammation  of  tiie  large  intestine,  Avith  necrotic  changes  at  the  surface 
of  the  membrane.  The  mesenteric  glands  are  enlarged.  There  may  be  more 
or  less  gastric  catarrh,  with  congestion  and  abrasion  of  the  mucous  surface. 
The  serous  membranes,  such  as  the  pleura  and  peritoneum,  are  dry  or 
covered  with  a  layer  of  sticky  albumin.  The  brain  and  its  membranes  may 
appear  normal  or  very  dry,  and  the  pia  may  be  oedematous  or  ecchymotic. 
The  cerebral  sinuses  contain  thickened,  dark  blood.  The  spleen  and  liver  are 
either  normal  or  anaemic  or  the  seat  of  parenchymatous  degeneration.  A  uremia 
of  tlie  liver  results  from  the  dniin  upon  the  intestinal  division  of  the  ])oi'tal 
.system  and  paresis  of  the  vessels.  The  kidneys  j)resent  the  appearances  com- 
monly produced  in  the  course  of  infectious  fevers.  The  tubidcs  contain  des- 
quamatrd  epithelium  and  hyaline,  granular,  or  fatty  casts.  The  cortex  is 
often  tiiickened  and  the  pyramids  are  congested.  The  bladder  is  contracted 
and  emptv.  The  heart  is  soft,  and  there  may  be  ecchymoses  in  the  jiericar- 
dium.  When  the  patient  has  died  f)f  asphyxia  the  left  ventricle,  as  usual  in 
such  cases,  is  comparatively  emj)ty,  while  the  right  ventricle  is  over-distended 


440  CHOLERA. 

with  dark  blood.  The  thickened  blood  coagulates  more  slowly  than  usual, 
and,  owing;  to  diminution  in  the  quantity  of  fibrin,  the  clot  is  less  firm.  The 
solid  ino-redients  are  present  in  quantity  one  and  a  half  times  greater  than  nor- 
mal (C.  Schmidt),  and  the  chlorides  are  found  to  have  transfused  into  the 
intestine,  leaving  a  relatively  larger  quantity  of  phosphates  behind.  The  red 
blood-corpuscles  appear  shrivelled,  and  both  red  and  white  corpuscles  are 
apparently  increased  in  number  on  account  of  the  diminution  in  serum.  The 
lungs  are  contracted,  dry,  pale,  and  anamic.  Pulmonary  cedema  is  rare. 
Congestion  is  sometimes  found  at  the  bases  of  the  lungs.  The  lungs  may 
weigh  as  little  as  twenty  ounces  (Sutton). 

Symptomatolog-y. — The  latent  period  or  incubation  which  intervenes 
between  the  time  of  infection  and  the  development  of  the  first  symptoms  is 
not  accurately  known.  In  a  majority  of  cases  it  is  two  or  three  days ;  it 
may,  however,  last  for  a  fortnight. 

The  symptoms  of  cholera  may  be  due  in  part  to  toxaemia  and  in  part 
to  the  sudden  and  extreme  drainage  of  water  from  the  system.  Thus  by 
some  observers  the  final  collapse  is  attributed  to  toxines  in  the  circulation 
which  cause  vaso-motor  spasm  and  impeded  pulmonary  circulation  (Johnson), 
while  others  believe  it  to  be  due  to  the  exhaustion  occasioned  by  the  profuse 
watery  evacuations  which  cause  desiccation  of  the  nerves  and  other  tissues  of 
the  body.  It  is  convenient  to  divide  the  symptoms  into  four  typical  stages,  as 
follows  : 

I.  The  premonitory  diarrhoea  ; 

II.  The  stage  of  serous  diarrhoea  ; 

III.  The  algid  stage,  or  stage  of  asphyxia  or  collapse ; 

IV.  The  reaction. 

These  stages  usually  occur  in  the  order  mentioned,  but  any  one  may  be 
omitted.  Thus,  the  premonitory  diarrhoea  may  be  absent  when  the  disease 
begins  with  the  second  stage,  or  it  may  be  the  only  symptom  present  in  cer- 
tain cases  during  the  progress  of  an  epidemic. 

Whether  this  stage  develop  or  not,  the  onset  of  the  disease  is  usually  sud- 
den, and  in  the  majority  of  cases  the  invasion  occurs  in  the  night.  More 
rarely  there  is  an  indefinite  prodromal  period  of  a  day  or  two,  with  more  or 
less  prostration,  vertigo,  anorexia,  and  gastric  oppression  with  flatulence. 

I.  The  first  stage,  when  present,  commences  with  a  diarrhoea,  and  the  stools 
are  alkaline,  watery,  yellowish  or  pale,  very  profuse,  and  frequently  voided. 
There  may  be  fifteen  or  twenty  within  twenty-four  hours.  These  stools  are 
(|uite  as  dangerous  as  regards  spreading  the  contagion  as  are  those  of  the 
fully-developed  disease.  There  are  borborygmi,  but  no  severe  colic.  There 
is  frontal  headache,  and  there  are  nausea  and  possibly  vomiting.  There  are  apt 
to  be  mental  depression  and  a  feeling  of  dread.  The  tongue  is  clean,  pale,  and 
moist  at  first,  bnt  later  becomes  dry.  Thirst  is  present  and  the  voice  grows 
tiiint.  These  symptoms  may  continue  for  a  day  or  two,  or  even  for  four  or 
five  days,  and  either  end  in  recovery  or  merge  into  the  second  stage. 

I I .  The  second  stage  presents  very  active  and  alarming  symptoms.    If  diar- 


SYMPTOMA  TOLOG  Y.  44 1 

rlioea  has  pre-existed,  it  continues  or  it  begins  anew.  In  citiier  case  the  stools 
are  very  copious,  alkaline,  and  watery,  and  their  passage  is  painless.  They 
are  often  excited  if  the  patient  turn  over  in  bed  or  if  pressure  be  made  over 
the  abdominal  wall.  The  stools  of  the  premonitory  diarrhoea  are  sero-mucous 
and  contain  more  or  less  bile  and  faecal  matter.  They  are  soon  followed  in 
the  second  stage  by  more  typical  evacuations.  The  typical  cholera  stools  are 
voided  after  the  bowels  have  been  emptied  of  their  ordinary  faecal  contents, 
and  are  usually  described  as  having  the  ap])earance  of  "rice-water"  or 
''macaroni-water."  They  have  no  odor  or  only  a  faint  "meaty"  smell. 
They  are  frothy,  and  contain  no  bile  or  faeces,  but  show,  in  suspension  in  an 
0])alescent  fluid,  whitish  flakes  which  are  composed  of  desquamated  intestinal 
ei)ithelium.  They  deposit  considerable  sediment  on  standing.  It  is  observed 
by  Milles  that  the  stools  are  almost  transparent,  and  thus  differ  in  appearance 
from  rice-water,  which  is  opaque.  They  are  occasionally  colored  by  extrav- 
iisated  blood,  in  which  case  they  are  described  as  resembling  the  lees  of  wine. 
The  specific  gravity  of  the  rice-water  evacuations  is  1005-1013  (Flint).  The 
reaction  is  alkaline  from  ammonium  carbonate,  but  the  principal  salt  is  found 
to  be  chloride  of  sodium.  The  quantity  of  the  fluid  discharged  in  a  single 
evacution  may  exceed  two  quarts,  and  its  passage  often  is  followed  bv  a  tem- 
porary feeling  of  ease. 

The  typical  cholera  stools  contain  a  lesser  variety  of  micro-organisms  than 
is  found  normally,  and  they  yield  an  almost  pure  culture  of  the  comma  bacillus. 
The  germs  are  not  found  in  any  quantity  until  the  stools  become  characteristic. 
Later,  in  the  stage  following  the  collapse,  the  stools  become  darker,  even  brown 
or  black  or  bloodstained,  and  they  are  slimy  and  very  malodorous.  It  is 
believed  that  the  cause  of  the  excessive  transudation  is  a  paralysis  of  the 
intestinal  nerves  (Brunton).  As  soon  as  a  considerable  quantity  of  fluid  has 
been  drained  off  in  the  frequent  serous  evacuations  the  thirst  becomes  more 
and  more  intense,  so  that  drinking  water  does  not  relieve  it.  There  is  rapid 
emaciation,  and  in  a  few  hours  the  victim,  who  may  have  been  previously 
robust,  presents  the  aspect  of  an  emaciated  and  old  man,  with  loose,  wrinkled, 
inelastic  skin,  sunken,  glaring  eyes,  and  a  parched,  dry  tongue.  The  scrotum 
is  markedly  retracted.  The  stomach  is  highly  irritable  and  rejects  nearly 
everything  which  is  swallowed.  There  are  nausea,  sudden  vomiting,  and  epi- 
gastric distress.  The  ejecta  consist  at  first  of  the  food  or  other  contents  of  the 
stomach,  then  become  bilious,  and  finally  are  clear  and  transparent,  with  floc- 
culi  of  mucus  resembling  the  rice-water  stools.  The  quantity  of  fluid  vom- 
ited exceeds  tiiat  which  is  druid<.  The  vomiting  may  occur  only  at  the  coni- 
mencement  of  the  disease,  but  it  usually  continues.  The  urine  is  thick,  turbid, 
and  contains  an  excess  of  urea,  and  later  more  or  less  all)umin,  with  granular 
and  hyaline  casts.  Urcn  is  said  to  be  also  eliminated  by  the  stomach,  and  in 
increased  amount  in  the  perspiration.  The  j)ulse  becomes  small  and  feeble, 
and  arterial  tension  is  (b'niinished.  The  (linnho'a  is  finally  ac('()iii])anie(l  by 
abdominal  cramps,  and  the  pains  extend  down  the  hgs  and  l)econie  agonizing. 
The  j)atieiit  is  restless,  anxious,  and  distressed,  and   becomes  more  and   more 


442  CHOLERA. 

feeble  and  prostrated.  The  pulse  becomes  very  weak  and  accelerated,  and  the 
respiration  may  be  shallow  and  somewhat  increased  in  frequency.  All  tiiis 
occurs  in  a  few  hours'  time.  The  temperature  of  the  surface  is  low  and  the 
skin  feels  cold  to  the  touch,  but  the  internal  temperature  is  elevated.  A 
cold,  clammy  perspiration  frequently  covers  the  entire  surface  of  the  body. 

The  mind,  as  a  rule,  remains  unclouded,  but  the  voice  is  feeble,  husky,  and 
high-pitched.  More  or  less  complete  suppression  of  urine  ensues,  due  either 
to  a  loss  of  water  or  to  local  action  of  the  poisonous  products  of  the  disease. 

There  is  an  occasional  variety  of  cholera  which  is  very  fatal,  and  in  which 
the  diarrhoea  is  wanting  but  the  other  symptoms  are  present.  This  is  known 
as  "dry  cholera"  or  "  cholera  sicca."  In  these  cases  the  intestine  is  found  at 
the  autopsy  to  be  greatly  distended  with  serous  exudate.  Hence  the  amount 
of  diarrhoea  is  not  an  infallible  indication  of  the  severity  of  the  disease. 
Sometimes  in  these  cases  the  patients  are  seized  with  great  prostration.  While 
walking  about  they  suddenly  become  faint,  dizzy,  and  unable  to  stand.  There 
are  headache  and  mental  confusion.  In  the  worst  cases  the  prostration  rapidly 
increases,  and  the  patient  dies  in  two  or  three  hours. 

In  the  serous  stage  the  amount  of  water  lost  from  both  stomach  and  intes- 
tines is  very  great.  It  comes  away  in  gushes,  frequently  from  both  stomach 
and  rectum  simultaneously,  or  it  may  flow  from  the  rectum  in  an  almost  con- 
tinuous stream.  There  may  be  spasm  of  the  diaphragm,  producing  hiccough, 
and  often  the  abdominal  muscles  become  tense.  The  spasms  and  cramps  of 
the  various  muscles  become  extremely  painfid,  particularly  in  the  legs.  These 
spasms  may  be  explained  4n  one  of  three  ways  :  they  may  be  due  to  toxic  prod- 
ucts in  the  blood,  to  reflex  gastro-intestinal  irritation,  or  to  desiccation  of  the 
nerve-centres  (Weir  Mitchell).  The  latter  explanation  is  probably  the  most 
correct.  There  are  sometimes  involuntary  contractions  of  the  flexors  and 
extensors  of  the  digits.  The  serous  stage  lasts  during  one  to  three  hours 
or  longer. 

If  tlie  symptoms  are  very  violent  the  second  stage  will  be  more  brief,  on 
account  of  the  exhaustion  of  the  T)atient.  It  is  followed  sometimes  by  reac- 
tion, but  more  frequently  by  the  stage  of  collapse. 

III.  TJie  Stage  of  Collapse. — In  this  stage  the  prostration,  emaciation,  and 
enfeebled  heart-action  continue.  The  face  becomes  shrunken  and  expression- 
less, the  cheek-bones  are  prominent,  the  cheeks  are  depressed,  the  nose  is 
sharp,  the  eyes  are  dry  and  hollow,  and  the  whole  physiognomy  is  highly 
typical  of  the  disease.  The  deeply  sunken  eyes  are  half  closed  and  sur- 
rounded by  dark  circles.  Tiie  forehead  is  wrinkled,  the  lips  are  thin  and 
set,  the  fingers  are  shrivelled,  and  the  radial  pulse  is  scarcely  perceptible. 
The  skin  is  duskv  or  blue,  and  feels  verv  cold  to  the  touch.  A  sudden 
increase  in  the  diarrhoea  or  vomiting  is  apt  to  be  accompanied  by  a  rapid  fall 
in  the  surface  temperature  (Shakespeare).  The  oral  temperature  falls  to  90^ 
or  95°  F.,  and  it  has  been  observed  as  low  as  79°  F.,  and  the  axillary  tem- 
perature may  fall  to  75°  F.,  but  the  fact  of  a  rise  of  deep  internal  tempera- 
ture has  been  confirmed  recently  by  a  number  of  competent  observers  (De 


SYMPTOM  A  rOL  O  G  Y.  44:i 

Renzi,  Gnterbock).  A  thermometer  carefully  pa.ss;ed  high  up  iuto  tlie  rec- 
tum may  record  an  elevation  of  temperature  amounting  to  two  degrees  above 
the  normal.  The  patient  complains  of  a  sensation  of  internal  heat.  The  fever 
is  said  to  be  of  a  remittent  type  Avith  evening  exacerbations.  It  is  often  over- 
looked on  account  of  the  stone-cold  feeling  of  the  surface  and  from  the  diffi- 
culty of  taking  the  temperature  in  the  rectum  while  the  stools  are  being  almost 
constantly  voided.  The  vomiting  and  diarrhoea  finally  cease,  apparentlv  from 
exhaustion  or  because  there  is  no  more  material  to  be  discharged.  'J'he  tips 
of  the  fingers  and  toes  become  livid  and  rigid,  and  the  breath  feels  cold.  The 
respirations  are  shallow  and  irregular,  and  dyspnoea  is  often  extreme.  The 
loss  of  so  much  fluid  from  the  blood  through  the  alvine  evacuations  causes 
diminution  in  all  other  secretions  of  the  body,  excepting  sometimes  the  per- 
spiration. The  tears,  saliva,  and  bile  are  withheld,  and  menstruation  is 
checked.  The  dryness  of  the  eyes  may  result  in  their  inflammation  from 
exposure  to  the  air  (Stille).  The  suppression  of  urine  contimies,  and  it 
may  become  complete.  If  any  urine  is  v^oided,  it  is  albuminous,  and  fre- 
quently contains  sugar. 

The  mind  remains  intelligent,  but  the  patient  is  too  feeble  and  too  greatly 
prostrated  in  every  way  to  speak  or  to  take  note  of  his  surroundings,  and  lies 
as  though  dead.  Tlie  blood,  thickened  by  deprivation  of  so  much  M'ater,  flows 
but  slowly  through  the  capillaries  and  lingers  in  the  veins  until  it  becomes 
highly  venous  all  through  the  body,  and  imparts  a  cyanotic  hue  to  the  entire 
surface,  and  the  condition  of  asphyxia  ensues,  which  Brunton  believes  is  due 
to  spasm  of  the  pulmonary  vessels  preventing  the  free  flow  of  blood  through 
the  lungs.  The  post-mortem  appearances  of  the  lungs  confirm  this  view. 
There  is  less  interchange  of  the  gases  of  respiration  than  there  should  be,  and 
elimination  of  carbon  dioxide  is  diminished.  The  pulse  is  feeble,  not  usually 
above  100  or  120,  and  it  may  fail  entirely  at  the  wrist.  The  second  sound 
of  the  heart  is  inaudible.  The  entire  body  is  shrunken  almost  beyond  recog- 
nition. 

This  stage  lasts  for  several  hours  as  a  rule,  or  it  may  be  j^rotracted  for 
a  day  or  two,  and  it  either  terminates  fatally  or  in  a  reaction  with  recovery. 
Death  may  be  due  to  asthenia  or  to  asphyxia,  but  profound  coma  is  uncom- 
mon. It  may  come  suddenly,  without  premonition,  and  patients  in  whom 
the  symptoms  have  not  been  very  severe  have  been  known  to  jump  out  of 
bed  and  walk  about  just  before  death  overtook  them.  More  often  death 
supervenes  gradually  with  progressive  coldness  of  the  surface  and  insensi- 
bility. "When  it  results  from  asphyxia  from  stagnation  of  the  blood,  the 
temj)erature  usually  rises  and  may  reach  108°  F.  In  other  cases,  after  death 
the  temperature  may  continue  to  rise  to  106°  F.,  and  there  may  be  post- 
mortem contractures  of  the  muscles  of  the  extremities  and  of  the  facial  mus- 
cles, producing  grimaces. 

It  will  be  observed  from  the  foregoing  account  (hat  nearly  all  (he  symp- 
toms of  cholera  are  induced  by  the  excessive  loss  of  fluid  from  the  blood. 
This  occasions  the  dryness  of  all  the  tissues,  the  diminution  in  biliary,  renal^ 


444  CHOLERA. 

and  other  glandular  secretions,  the  paralysis  of  the  nervous  system,  the 
exhaustion,  and  the  asphyxia. 

IV.  The  Reaction. — The  great  majority  of  patients  who  recover  pass 
through  a  reactionary  febrile  stage.  The  reaction  follows  either  the  stage  of 
serous  diarrhoea  or  the  collapse.  The  external  temperature  rises,  while  the  inter- 
nal temperature  falls,  and  the  condition  of  tlie  circulation  is  gradually  restored 
to  the  normal.  The  face  regains  its  natural  expression.  Tlie  cramps  and  vom- 
iting cease.  The  pulse  becomes  slower  and  of  better  volume,  and  thirst  is  no 
longer  complained  of.  The  stools  become  of  firmer  consistence,  and  finally 
resume  their  Isecal  character  and  contain  bile-pigment,  except  in  those  cases  in 
which  there  has  been  extensive  denuding  of  the  epithelial  surface  of  the  intes- 
tine, when  the  stools  may  be  hsemorrhagic  for  some  time.  The  secretion  of 
the  urine  is  gradually  restored.  In  some  cases  convalescence  is  interrupted 
by  absorption  of  septic  matter  from  this  denuded  surface,  and  a  typhoid  con- 
dition or  septic  fever  results,  with  considerable  elevation  of  temperature,  a  dry 
tongue,  delirium,  and  coma.  Various  cutaneous  eruptions  may  accompany  the 
fever.  If,  on  the  other  hand,  convalescence  be  not  delayed  by  typhoid  symp- 
toms, there  are  usually  pronounced  aneemia  and  prolonged  irritability  and  fee- 
bleness of  the  digestive  organs  and  of  the  nervous  system.  There  are  severe 
frontal  headache,  and  often  vertigo  and  fainting.  In  still  other  cases  ursemic 
symptoms  develop,  the  function  of  the  kidneys  not  having  been  restored.  In 
such  instances  nervous  symptoms  predominate,  and  there  is  delirium  with  con- 
vulsions. 

In  some  cases  the  intestines  fail  to  recover  their  tone,  and  an  exhausting 
diarrhoea  still  further  debilitates  the  patient.  Relapses  may  occur,  either  as  a 
result  of  indiscretion  in  diet  or  exertion  or  without  assignable  cause. 

In  the  variety  of  disease  called  "cholerine"  the  symptoms  are  compara- 
tively mild,  although  they  may  last  for  a  week.  Asphyxia,  cramps,  and  total 
suppression  of  urine  are  sometimes  absent. 

Complications  and  Sequelae. — Diarrhoea,  dysentery,  and  malarial  fevers 
are  apt  to  prevail  in  the  same  localities  with  cholera  and  at  the  same  time  with 
cholera  epidemics,  though  the  latter  disease  is  so  acute  that  it  is  rarely  compli- 
cated by  other  affections  unless  they  already  exist  in  the  individual  attacked. 
Various  exanthemata,  such  as  roseola,  urticaria,  etc.,  may  occur  during  the 
reaction  or  the  convalescent  period.  Sometimes  furunculosis  and  ulceration 
ensue,  especially  upon  the  emaciated  extremities.  Bed-sores  are  apt  to  occur. 
Excessive  perspiration,  with  elimination  of  increased  urea,  is  sometimes 
observed.  There  may  be  painful  swelling  of  the  parotid  glands,  rarely 
progressing  to  the  formation  of  abscess.  Sometimes  a  painful  contraction  of 
the  nmscles  of  the  extremities  resembling  tetanus  takes  place,  and  lasts  for 
several  hours  or  a  day  or  two.  Gangrene  and  peritonitis  have  been  rarely 
present  as  sequelae.  Corneal  ulcers  sometimes  appear.  More  or  less  gastro- 
intestinal irritability,  with  gastralgia  and  anorexia,  is  apt  to  remain,  and  it 
may  last  for  many  weeks,  greatly  retarding  convalescence.  There  may  be 
enfeebled  circulation,  with  cold  extremities  and  wakefulness.     Various  kidney 


B  URA  TION.—DIA  GNOSIS.  445 

lesions  have  sometimes  followed,  and  cerebral  congestion  may  be  a  sequel  to 
the  reactionarv  jieriod.     Pneumonia  is  an  occasional  com[)lication. 

Duration. — Fatal  cases  end  usually  in  two  or  three  days.  Death  has 
occurred  within  two  hours  after  the  first  typical  stools  have  appeared. 
In  such  cases  all  the  symptoms  of  the  algid  stage  occur  with  incredible 
rapidity.  The  duration  of  a  single  epidemic  is  often  brief,  and  it  seldom 
remains  a  month  in  any  one  locality. 

Diag-nosis. — Cholera  is  liable  to  be  confounded  with  one  or  two  other 
diseases  in  its  early  stage  and  before  the  epidemic  has  been  recognized.  After 
the  establishment  of  an  epidemic  the  disease  is,  however,  readily  identified  by 
the  typical  stools,  ra])id  emaciation,  great  thirst,  prostration,  and  algid  con- 
dition. The  diseases  and  conditions  with  which  cholera  may  be  confounded 
are  septicaemia,  typhoid  fever,  pernicious  malarial  fever  of  the  gastro-enteric 
variety,  cholera  nostras,  and  ptomaine  or  mineral  poisoning. 

In  the  typhoid  or  reactionary  stage  of  cholera  the  patient  is  really  in  a 
septic  condition,  and  the  prostration,  emaciation,  and  general  ataxic  condition 
suggest  enteric  fever.  The  latter  disease,  however,  has  a  protracted  history  : 
there  is  a  characteristic  temperature  curve,  a  rose-colored  abdominal  eruption, 
and  diarrhoea,  if  present,  is  of  a  different  sort,  and  the  stools  are  less  watery 
and  colorless  than  in  cholera.  The  gastro-enteric  variety  of  malarial  fever  is 
oflen  so  severe  as  to  resemble  cholera  in  its  earlier  stage.  In  the  former  the 
temperature  is  high,  106°  or  107°  F. ;  the  stools  may  be  bloody  at  first;  v^om- 
iting,  if  present,  is  more  painful,  with  decided  retching ;  and  free  ])igment  is 
found  in  the  blood,  with  possibly  the  malarial  plasmodium. 

Very  severe  cases  of  cholera  morbus  may  prove  fatal  in  one  or  two  days, 
and  every  symptom  of  cholera  may  be  present,  rendering  diagnosis  extremely 
difficult.  Fortunately,,  such  cases  are  quite  exceptional.  Usually  in  cholera 
nostras,  or  sporadic  cholera,  the  symptoms  of  extreme  cyanosis  and  total  sup- 
pression of  urine  are  wanting.  The  alvine  evacuations  are  loose  and  watery, 
but  unlike  the  typical  "rice-water"  stools.  The  disease  is  less  rapid  than 
true  cholera  in  its  progress,  much  less  severe  in  its  symptoms,  and  recovery 
is  more  frequent.  The  cases  are  isolated  and  non-contagious.  The  typical 
cholera  bacillus  is  absent.  The  cramps  are  apt  to  be  more  severe  in  the 
stomach,  but  less  severe  in  the  legs,  than  in  true  cholera. 

Asphyxia  from  coal-gas  (CO)  poisoning  may  produce  symptoms  resembling 
the  asphyxia  stage  of  cholera,  but  the  absence  of  intestinal  irritation  and  of  the 
typi(!al  choleraic  stools  will  at  once  confirm  the  diagnosis. 

In  cases  of  mineral  poisoning  there  may  be  visible  corrosion  within  the 
mouth,  a  metallic  taste,  and  the  epigastric  pain  and  burning  is  very  pro- 
nounced. The  stools  are  bloody  or  foetid,  instead  of  clear  and  watery. 
Among  such  cases  the  symptoms  produced  by  arsenic  are  the  most  difficult 
to  diflf'erentiate  from  those  of  cholera,  for  in  both  instances  there  may 
be  great  prostration,  collapse,  thirst,  cramps,  and  supj>r(>ssion  of  urine. 
In  acute  arsenical  poisoning  there  is  usually  constriction  felt  in  the  throat 
or  oesophagus,  and  there  is  epigastric  pain  of  an   intense  burning  character. 


446  CHOLERA. 

The   symptoms   commonly   follow   very  soon   after  the  taking  of  drink  or 

food. 

In  any  doubtful  instance  the  discovery  of  the  cholera  bacilli  in  the  stools 

will  decide  the  case. 

Prognosis  and  Mortality. — The  prognosis  depends  uj^on  the  severity  of 
the  epidemic,  the  sanitary  condition  of  the  environment,  the  habits  of  life, 
and  the  promptness  with  which  the  patient  comes  under  treatment.  For 
cases  seen  very  early  the  prognosis  is  good.  It  is  bad  in  densely-populated 
districts,  and  worse  near  the  seacoast  than  inland. 

The  mortality  from  Asiatic  cholera  remains  practically  unreduced  by  every 
effort  of  treatment,  although  if  seen  early  and  faithfully  treated  many  cases 
may  be  brought  to  recovery.  The  disease,  once  established  among  those  of 
filthy  habits,  is,  however,  nearly  as  fatal  as  ever.  The  total  number  of  cases 
occurring  in  a  given  locality  is  diminishing  where  hygienic  laws  are  duly 
respected.  Thus,  in  1868  the  cholera  mortality  among  foreign  soldiers  in 
India  was  18.6  per  1000,  while  to-day  it  is  only  one-sixth  as  great.  The 
general  mortality  varies  between  20  and  80  per  cent,  with  different  epidemics, 
but  it  is  always  high,  and  the  hospital  death-rate  may  often  exceed  60  per 
cent.  It  has  been  as  grave  as  90  per  cent.  The  worst  mortality  occurs  during 
the  earlier  and  middle  period  of  an  epidemic :  toward  the  end  the  cases  are 
less  fatal.  The  disease  is  very  fatal  in  childhood  and  old  age,  but  is  less  com- 
mon among  such  subjects  ;  hence  the  mortality  is  greatest  in  adult  or  middle 
age.  An  epidemic  may  aifect  a  very  large  number  of  persons,  and  yet  the 
death-rate  may  be  lower  than  in  a  less  extensive  epidemic. 

Prophylaxis. — The  prophylactic  treatment  consists  in  a  rigid  enforcement 
of  sanitary  rules  and  personal  hygiene.  All  healthy  persons  should,  as  far  as 
practicable,  be  removed  from  the  infected  district.  Great  importance  attaches 
to  immediately  stopping  any  diarrhoea  which  occurs  while  an  epidemic  of 
cholera  is  prevalent,  and  to  further  this  end  it  is  advisable  for  the  local  gov- 
ernment to  appoint  special  medical  inspectors  to  go  from  house  to  house.  In 
this  manner  many  lives  may  be  saved. 

The  digestion  should  be  particularly  cared  for,  and  some  advise  the  internal 
use  of  dilute  acids  to  maintain  a  moderate  hyperacidity  of  the  stomach,  which 
is  thereby  rendered  inimical  to  the  germs.  Fatigue  and  excesses  of  all  sorts 
should  be  strenuously  avoided.  All  sewers,  privies,  cesspools,  and  water-tanks 
should  be  thoroughly  cleansed  and  disinfected.  Drinking  of  impure  water 
should  be  avoided,  and  all  water  should  be  thoroughly  boiled  before  use. 
During  the  prevalence  of  an  epidemic  all  public  funerals  or  large  gatherings 
of  people  shoidd  be  absolutely  interdicted. 

Treatment. — No  one  drug  or  system  of  treatment  has  proved  of  much 
avail  for  cholera.  The  objects  of  treatment  are,  therefore — (1)  to  support  the 
strength  ;  (2)  to  allay  pain  and  fear  ;  (3)  to  relieve  the  severity  of  certain 
symptoms,  notably  the  thirst,  emesis,  diarrhoea,  and  cramps ;  (4)  to  prevent 
thickening  of  the  blood  and  suppression  of  urine.  The  treatment  must  be 
adapted  to  each  stage  of  the  disease. 


TREA  TMENT.  447 

Treatment  of  the  First  Stage. — If  promptly  taken  in  lianil  at  tlie  outset  and 
carefully  watched  and  nursed  throughout  the  disease,  a  certain  projMM'tion  of 
oases  may  be  saved,  and  in  some  the  disease  is  apparently  aborted.  With  the 
first  indication  of  diarrhoea  the  patient  must  go  to  bed  and  remain  there, 
warmly  covered.  He  must  be  kept  absolutely  quiet  throughout  the  disease. 
Hot  stupes  may  be  placed  over  the  abdomen  and  food  should  be  withheld.  A 
dose  of  laudanum  or  chlorodyne  is  to  be  given  at  once,  and  then  salol  or  sali- 
cylate of  bismuth  may  be  administered  every  two  hours.  It  is  believed  that 
the  salol  acts  as  an  antifermentative  and  prevents  the  absorption  of  ptomaines 
from  the  intestine.  In  many  cases  this  prompt  treatment  will  stop  the  diar- 
rhoea, and  the  disease  may  advance  no  farther.  In  the  early  stages  of  the  dis- 
ease it  is  useless  to  attempt  to  give  food.  The  stomach  is  too  irritable,  and 
broths  and  milk  serve  only  as  cidture  media  for  the  further  development  of 
the  bacilli. 

Treatment  of  the  Second  Stage. — If,  on  the  other  hand,  the  diarrha-a  ])ro- 
gresses,  and  the  alvine  discharges  become  serous  and  are  accompanied  by 
cramps,  more  active  measures  are  imperative,  and  every  effort  should  be  made 
to  keep  up  the  patient's  hope  and  courage  for  the  struggle  which  is  before  him. 
The  abdomen  may  be  wrapped  in  flannel,  or  turpentine  stupes  are  useful  if  the 
abdominal  pains  are  severe.  For  the  vomiting  morphine  should  be  given 
hypodermically,  and  a  mustard  paste  placed  over  the  epigastrium.  Cracked 
ice,  cold  lime- wafer,  carbonic-acid  water,  or  iced  champagne  sometimes  afford 
relief.  When  it  can  be  obtained,  fresh  lime-juice,  iced,  is  very  serviceable. 
Cocaine  in  small  doses  sometimes  allays  the  gastric  irritability.  The  cramps 
in  the  calves  of  the  legs  and  other  muscles  may  become  so  intense  as  to  require 
inhalation  of  chloroform  for  their  relief.  Kneading  the  muscles  is  sometimes 
of  use,  as  well  as  rubbing  them  with  mustard-water  and  applying  hot-water 
bottles  and  turpentine  stupes  to  the  legs. 

It  is  strongly  recommended  by  certain  writers  of  extensive  experience  to 
place  the  patient  in  a  hot  bath,  at  106°  or  108°,  for  twenty  minutes  during 
the  stage  of  cramps  and  commencing  serous  diarrhoea.  The  patient  is  then  put 
back  to  bed,  rubbed  dry,  wrapped  in  warm  blankets,  and  is  given  warm,  stim- 
ulating, and  aromatic  drinks.  Of  course  he  should  be  moved  as  little  as  ])()s- 
sible,  and  should  be  lifted  into  and  out  of  the  hot  bath.  Should  his  condition 
warrant  it,  the  bath  is  to  be  repeated  once  in  two  or  three  hours.  It  quiets  the 
nervous  system,  arrests  the  vomiting,  controls  the  painful  cramps,  restores  the 
skin  to  a  more  natural  condition,  and  stimulates  the  circulation  ;  besides  which 
it  is  usually  very  grateful  to  the  patient.  For  the  agonizing  thirst  cold  water, 
acidulated  with  a  little  dilute  hy(h"ochloric  or  ph()s))iiori(!  acid  or  lemon-juice, 
sliould  be  irivcn.  Cracked  ice  is  useful,  but  the  relief  alTorded  bv  it  is  slio-ht. 
Carbonic-acid  water  or  seltzer  may  also  be  given.  Fluid  held  in  the  mouth  for 
ten  minutes  at  a  time  affords  more  relief  than  when  imnic<liately  swallowed, 
by  giving  a  sort  of  local  bath  to  the  parched  tongue. 

The  serous  diarrhfca  is  not  readily  controlled  by  i-emedies  administered 
bv  the  mouth,  because  they  are  scarcely  absorbed  at   nil,  but  cuemata  of  ten 


448  CHOLERA. 

grains  of  lead  subacetate  or  of  tannin,  in  fonr  ounces  of  water  with  fifteen  or 
twenty  minims  of  tinct.  opii,  may  be  employed  with  advantage. 

In  order  to  replace  the  fluid  which  drains  away  in  such  large  amount  in 
the  serous  stools,  and  to  restore  the  balance  of  the  blood-pressure,  volume,  and 
density,  it  is  necessary  to  put  back  fluid  into  the  body  in  some  manner.  The 
stomach,  owing  to  excessive  irritability,  is  useless  for  this  purpose,  and  two 
other  methods  have  therefore  been  recently  advocated  by  Cantani  of  Naples, 
and  extensively  tried  by  himself  and  others  with  very  favorable  results.  The 
first  is  termed  "  entero-clysis,"  and  is  adapted  to  both  the  second  and  third 
stages  ;  the  second,  "  hypodermo-clysis,"  is  adapted  to  the  third  stage.  Entero- 
clysis  is  performed  by  injecting  the  following  solution  through  a  long,  flexible 
rubber  rectal  tube,  which  may  be  passed  up  carefully  for  a  foot  or  more  into 
the  gut : 

I^.  Boiled  water  or  infusion  of  chamomile,        2  litres; 
Tannin,  5-10  gr. ; 

Laudanum,  30-50  gtt. 

Powdered  gum  arable,  50  gr. — M. 

Sig.    Inject  per  rectum  immediately  after  an  evacuation  (Shakespeare). 

Treatment  of  the  Third  Stage  by  Hypodermodysis. — This  operation  is  de- 
scribed by  Shakespeare  as  follows :  The  object  is  to  inject  large  quantities  of 
fluid  beneath  the  skin  for  absorption  into  the  blood-vessels  and  lymphatics. 
A  large  fold  of  skin  is  raised  between  the  thumb  and  finger  in  the  infraraam- 
raary  or  ileo-costal  region,  and  a  canula  is  inserted  between  the  skin  and  sub- 
cutaneous fascia.  The  canula  is  connected  by  rubber  tubing  with  a  fountain 
syringe,  and  the  contents  of  the  latter  are  allowed  to  slowly  flow  in  by  gentle 
force  of  gravity  until  one  or  two  litres  of  fluid  have  been  injected.  The  skin 
over  the  site  of  the  injection  may  be  rubbed  a  little  in  order  to  distribute  the 
fluid.  The  injection  should  be  made  slowly,  and  twenty  minutes  or  half  an 
hour  will  be  required  for  the  process.  Of  course  the  ordinary  precautions 
taken  in  any  transfusion  operation  must  be  observed  as  regards  prevention  of 
entrance  of  air  and  antiseptic  cleanliness  of  the  instrument  employed.  A 
stopcock  should  be  arranged  to  control  the  volume  of  fluid.  The  salt  solution 
injection  is  prepared  as  follows : 

I^.  Chloride  of  sodium,  c.  }).,  80 ; 

Sodium  carbonate,  6. 

Sig.  Dissolve  in  two  litres  of  boiled  water,  and  inject  at  the  normal  tem- 
perature of  the  blood. 

The  indications  for  the  use  of  this  method  of  treatment  are  the  signs  of 
lack  of  water  in  the  vascular  system,  cramps,  a  cold,  discolored  skin,  rapid 
emaciation,  and  copious  serous  discharge.  It  is  said  to  produce  very  striking 
effects,  .and  to  arouse  patients  from  profound  collapse  and  cure  them.  The 
water  thus  supplied  to  the  system  through  the  rectum  and  the  skin  aids  in 


TREA  TMENT.  449 

washing  out  the  waste  matter  formed  in  the  body  and  in  eliminating  the  toxic 
])rineiples  which  have  been  absorbed  and  are  overwhelming  the  system.  The 
kidneys  are  thus  restored  to  their  natural  activity.  Should  a  favorable  reac- 
tion not  follow  almost  immediatelv,  and  if  the  skin  remain  cold,  the  sub- 
cutaneous  injection  must  be  repeated. 

Atropine  has  been  combined  with  opium,  with  the  idea  of  counteracting  the 
ptomaines  produced  in  the  intestine,  which  resemble  nuiscarin  in  the  intensity 
of  poisonous  effect  (Brunton).  Salol,  naphthaline,  creolin,  and  allied  remedies 
have  been  given  internally,  with  the  object  of  checking  the  diarrhoea,  of  con- 
trolling intestinal  fermentation,  and  of  preventing  the  formation  of  ptomaines. 
Of  these  remedies  salol  is  the  most  useful. 

In  the  stage  of  collapse  every  effort  should  be  made  to  maintain  the  circu- 
lation until  the  danger  is  passed,  and  most  prompt  and  vigorous  action  is 
necessary  or  the  })atient  will  die  in  two  or  three  hours.  Hypodermic  stimula- 
tion may  be  pushed  with  sulphuric  ether,  strychnine,  brandy,  camphor,  caf- 
feine, or  morphine.  Hot-water  bottles,  hot-air  baths,  and  hot  fomentations 
are  required.  The  perspiration  should  be  wiped  off  as  it  forms.  Internally, 
warm  alcoholic  stimulants,  camphor,  and  ammonium  carbonate  may  be  given, 
provided  the  stomach  will  retain  them.  Intravenous  and  intraperitoneal 
injections  have  been  attempted,  but  with  little  result.  Inhalations  of  oxygen 
or  of  amyl  nitrite  have  proved  useful  in  some  cases  of  collapse. 

In  convalescence  fluid  nourishment  only  should  be  given,  and  this  at  fre- 
quent  intervals  and  in  small  amount,  increasing  the  quantity  and  diminishing 
the  frequency  as  the  patient  imj^roves.  The  stomach  remains  weak  and  irrita- 
ble for  so  long  a  period  that  solid  food  must  be  postponed  for  many  days,, 
and  milk,  beef  peptonoids,  and  nutritious  broths,  M'ith  champagne,  shotdd  be 
the  dietary  limit  at  first.     Strychnine  and  other  bitter  tonics  are  helpful. 

Frequent  examinations  of  the  urine  should  be  made,  and  attention  must  be 
paid  to  the  restoration  of  the  functions  of  the  kidneys.  Mild  diuretics  and 
saline  effervescent  waters  may  be  indicated  for  this  purpose. 

The  disinfection  required  after  a  case  of  cholera  has  terminated  is  ex- 
tremely thorough.  Rooms  and  hospital  wards  should  be  fumigated ;  i\\e 
floors  and  walls  and  furniture  shoukl  be  washed  with  solutions  of  corrosive 
sublimate,  1  :  1000,  or  other  disinfectant;  and  tlie  walls  should  be  rubbed 
down  with  bread  to  remove  any  dust  or  germs  which  may  cling  to  them.  The 
patient  should  be  bathed  and  then  sponged  with  a  1  :  1000  corrosive-sublimate 
solution  (care  being  taken  to  keej)  it  from  the  eyes).  Bedding  and  clothing 
should  be  destroyed  by  fire  when  possible  or  disinfected  in  superheated  steanu 
Linen  must  be  boiled. 

It  must  be  constantly  borne  in  mind  that  cleanliness  is  absolutely  essential, 
and  too  much  reliance  is  not  to  be  placed  upon  disinfectant  materials.  The 
stools  and  vomited  matter  must  be  treated  with  strong  disinfectants.  All 
d(jections  should  l)e  received  in  a  vessel  coiitainiiig  cither  a  1  :  1000  corro- 
sive-sublimate solution  or  a  5  ])cr  c(!nt.  solution  of  carbolic  a(;Id  to  which  a 
little  crude   hydrochloric  at^d   has  been  added.     This  solution  should  equal 

Vol.  I.— 29 


450  CHOLERA. 

half  tlie  volume  of  the  stool.  Schaiiz  advises  the  addition  to  the  stool  of  one- 
sixth  of  its  volume  of  a  solution  made  by  adding  100  gr.  of  crude  sulphuric 
acid  to  a  litre  of  water.  After  disinfection  the  stool  should  be  buried  in  a 
trench  or  mixed  with  sawdust  and  burned  (Stille),  for  the  acid  is  ruinous  to 
drain-pipes.  It  should  be  remembered  that  the  germ  is  relatively  feeble  when 
first  voided,  and  the  stools  are  therefore  rendered  more  thoroughly  inert  if 
disinfected  at  once.  Soon  after  exposure  to  the  air  the  germ  increases  in  vir- 
ulency. 

The  question  of  quarantine  has  given  rise  to  much  discussion,  but  it  can- 
not here  be  argued  in  detail.  It  has  often  proved  ineffectual,  and  many 
believe  that,  so  long  as  their  clothing  and  luggage  are  disinfected,  apparently 
healthy  persons  coming  from  an  infected  district  need  not  be  detained  at  all. 
On  the  other  hand,  it  is  an  established  fact  that  the  disease  may  be  spread 
through  the  agency  of  the  premonitory  diarrhcea  before  the  individual  really 
feels  ill  at  all,  and  the  fact  that  quarantine  is  often  inefficacious  is  no  argument 
against  employing  it  as  rigidly  as  possible. 

When  there  has  been  an  outbreak  of  cholera  upon  a  vessel  it  should  be 
most  thoroughly  fumigated  and  cleansed,  and  all  persons  on  board  must  be 
removed  and  strictly  isolated  for  not  less  than  a  week  or  ten  days,  while  all 
their  clothing  and  luggage  is  disinfected. 


YELLOW  FEVER. 

By  W.  GILMAN  THOMPSON. 


Definition. — Yellow  fever  is  an  acute,  liighly  infectious,  but  non-con- 
tagious, disease,  characterized  by  a  sharp  febrile  paroxysm,  black  vomit, 
jaundice,  and  suppression  of  urine.  It  is  both  endemic  and  epidemic,  and 
is  confined  within  certain  geographical  limits.  The  first  recorded  epidemic 
occurred  in  Barbadoes  in  the  year  1647. 

Synonyms. — Black  vomit ;  Yellow  Jack  ;  Bronze  John  ;  Febris  flava  ; 
Haemo-gastric  fever ;  Gelbfieber  (Ger.). 

Etiology. — The  mode  of  propagation  of  yellow  fever,  as  well  as  its  be- 
havior as  a  disease,  leaves  no  reasonable  doubt  that  it  is  of  germ  origin. 
Several  bacteria  have  been  described  as  })athognomonic,  and  in  Havana  since 
1854  and  in  Brazil  protective  inoculations  have  from  time  to  time  been  prac- 
tised on  man,  but  the  most  experienced  bacteriologists  have  been  unable  to 
confirm  the  specific  character  of  these  germs,  and  we  are  still  in  ignorance  as 
to  their  nature  and  a{)pearance.  Several  times  organisms  found  in  yellow 
fever  wliieh  were  supposed  to  be  specific  have  been  subsequently  identified 
with  germs  occurring  in  other  affections.  Various  micro-organisms  have 
been  isolated  from  the  liver  and  kidneys  of  patients  dying  of  yellow  fever, 
and  Sternberg  found  a  bacillus  somewhat  resembling  that  of  cholera.  He 
reports  finding  in  the  liver  and  intestines,  after  death  from  yellow  fever, 
one  germ  which  he  considers  unique.  Cultures  of  the  germ  must  be  made 
very  soon  after  death,  and  comparatively  few  specimens  are  found.  It 
is  supposed  that  yellow-fever  microbes  may  enter  the  lungs  through  the  air 
and  be  transmitted  thence  to  the  blood,  or  possibly,  entering  the  mouth,  may 
convey  the  germ  to  the  saliva,  which  furnishes  a  culture  mc<lium.  Thence 
they  may  enter  the  alimentary  tract  and  be  absorbed. 

There  are  some  features  of  close  analogy  between  yellow  fever  and  the 
Southern  cattle  plague   or  Texas  fever,  wliich   is  also  a  germ   disease. 

It  is  claimed  in  Havana  that  mosquitoes  after  biting  a  yellow-fever  patient 
are  capable  of  inoculating  with  the  disease  the  next  healthy  person  whom 
they  attack  (Finlay). 

The  true  home  of  yellow  fever  is  in  flic  tropics.  It  extends  to  the  tem- 
])erate,  but  never  to  tlu;  frigid,  zone,  and  it  is  more  restricted  in  its  distribu- 
tion than  any  other  acute  infectious  disease,  showing  at  times  very  curious 
localization.  It  is  common  in  Mexico,  and  is  endemic  in  the  West  Indies, 
Panama,  and  on  the  east  coast  of  South  America,  where  it  periodically 
bec(;mes  epidemic,  and  thence  is  conveyed  in  sliips  or  by  mercluuulise  to  other 

451 


452  YJELLOW  FEVER. 

countries  to  promptly  establish  a  local  epideuiic.  It  is  thus  occasionally  found 
in  Southern  Europe,  the  west  coast  of  Africa,  and  on  the  southern  and  eastern 
coasts  of  the  United  States,  where  it  is  not  endemic  or  sporadic. 

When  introduced  by  vessels  into  the  United  States  it  prevails  chiefly  in 
July  and  August.  There  was  a  very  severe  epidemic  in  Florida  in  1887-88, 
and  one  in  Brazil  in  1889.  In  1890  it  prevailed  in  Brazil,  Costa  Rica,  Cuba, 
Mexico,  the  United  States  of  Colombia,  and  cases  were  detained  by  quarantine 
in  New  York  and  elsewhere.  Cases  have  been  carried  as  far  north  as  Quebet^ 
In  the  United  States  the  disease  has  never  become  really  endemic,  although  at 
New  Orleans  it  has  been  imported  in  forty-eight  different  years  out  of  the  first 
sixty  years  of  the  present  century  (Sternberg). 

A  single  epidemic  may  last  a  few  weeks  or  two  or  three  months,  until  its 
energy  is  spent  or  cut  short  by  frost.  The  average  duration  of  yellow-fever 
epidemics  is  forty-eight  days  (Barlow). 

The  following  facts  are  admitted  by  those  who  have  had  the  most  extensive 
experience  with  the  disease :  The  infected  area  extends  rapidly,  but  is  checked 
by  streams,  high  walls,  and  sometimes  by  thoroughfares.  Hence  the  poison 
keeps  near  the  ground.  Immunity  increases  with  elevation  above  the  sea,  and 
it  is  almost  complete  at  3000  feet.  The  majority  of  cases  occur  below  750 
feet.  Exceptionally,  however,  the  disease  has  appeared  at  much  higher  eleva- 
tions— for  example,  at  Cuzco  in  the  Peruvian  Andes,  which  is  over  11,000  feet 
above  the  sea. 

The  virus  is  destroyed  by  extreme  heat  and  by  cold.  One  or  two  frosts 
stop  an  epidemic  immediately,  but  freezing  does  not  necessarily  destroy  the 
germ.  Epidemics  stopped  by  a  severe  frost  have  spread  again  with  renewal 
of  a  warm  temperature,  as  was  the  case  at  Memphis,  Mississippi,  in  1878-79. 
The  disease  has  existed  when  the  mean  temperature  was  as  low  as  50°  F. 
(Forrest),  and  epidemics  may  continue  at  60°  to  70°  F.,  but  they  are  more 
virulent  at  a  temperature  five  or  ten  degrees  higher.  They  sometimes  cease 
from  lack  of  fresh  subjects  to  aifect,  and  break  out  again  when  strangers 
arrive. 

The  disease  invades  seaport  cities  and  towns  rather  than  rural  districts,  but 
it  follows  up  the  course  of  navigable  rivers. 

It  is  believed  by  the  majority  of  the  most  competent  observers  that  the 
germ  is  not  directly  contagious  from  one  individual  to  another,  but  that  it 
lodges  in  the  air,  or  upon  the  surface  of  neighboring  objects,  where  it 
matures.  Those  who  apparently  have  contracted  the  disease  from  the  person 
of  yellow-fever  patients  have  been  shown  to  have  been  infected  rather  through 
fomites  contained  in  the  same  house  or  ship,  and  not  by  direct  transmission 
from  one  body  to  another. 

Substances  which  readily  act  as  fomites  are  hair,  feathers,  cotton,  wool, 
linen,  etc.  By  these  agents  the  poison  is  carried  to  great  distances  in  the 
clothing,  luggage,  or  merchandise  from  an  infected  district.  When  protected 
it  preserves  its  vitality  for  a  long  period — at  least  a  year — and  Avhen  by  open- 
ing a  cesspool  or  cleaning  out  a  drain  or  renovating  an  old  house  it  is  subjected 


ETIOLOGY.  453 

to  favorable  conditions,  its  activity  is  renewed  and  it  gives  rise  to  a  fresh  epi- 
demic of  the  disease.  Tiiese  conditions  are  moisture  and  a  minimum  temper- 
ature of  72°  F.  Emanations  from  decavino-  animal  and  vegetable  matter  or 
fteces  and  poor  sanitation  also  favor  the  spread  of  the  disease.  It  might  con- 
ceivably be  exterminated  by  perfect  public  and  private  hygiene.  It  is  not 
conveyed  by  food  or  drinking-water,  and  it  loses  its  toxicity  in  abundant  fresh 
air,  and  consequently  the  disease  is  not  spread  far  by  the  atmosphere  alone, 
and  heavy  rains,  by  clearing  the  air  and  cleansing  the  soil,  diminish  the  force 
of  an  epidemic. 

Provided  that  the  clothing  be  disinfected,  the  disease  is  not  conveyed  by 
either  the  dead  or  living  body.  Yellow  fever  may  break  out  on  ships  after 
sailing  from  infected  ports.  If  the  patients  on  reaching  a  northern  port  are 
disinfected  and  all  fomites  are  removed  from  them,  they  may  be  safely  treated 
on  shore  without  fear  of  exciting  contagion  or  epidemic. 

Although  transmitted  for  short  distances  through  the  atmosphere,  the  virus 
tends  to  become  greatly  concentrated  and  violent  in  effect  in  certain  crowded 
localities,  where  it  may  remain  confined,  leaving  other  districts  in  the  same 
city  in  perfect  immunity.  It  prefers  low-lying  regions  along  the  coast,  espe- 
cially the  mouths  of  rivers,  and,  like  malarial  poison,  it  is  more  virulent  by 
night  than  by  day.  Typhoid  and  malai'ial  fevers  are  apt  to  be  prevalent 
during  yellow-fever  epidemics,  but  they  do  not  occur  together  in  the  same 
individual. 

Age. — Very  young  infants  usually  escape  the  disease  or  have  it  in  such  a 
light  form  that  it  is  overlooked.  It  has  been  reported,  however,  in  a  child 
only  ten  weeks  old.  Inflints  are  less  exposed  than  adults  to  the  conditions 
which  favor  the  spread  of  the  fever,  and  they  may  escape  on  that  score.  The 
very  old,  for  a  similar  reason,  may  escape  entirely,  but  the  disease  has  been 
observed  at  all  ])eri()ds  of  life  up  to  eighty  years. 

^^ex  exerts  no  decided  influence  on  the  spread  of  yellow  fever,  but  it  is 
especially  fatal  among  white  males  between  the  ages  of  twenty  and  forty  years. 
Males  are  more  apt  to  visit  infected  localities,  and  a  larger  number  of  males 
than  females  may  contract  the  disease  on  that  account. 

Race. — White  robust  adults  in  the  ])rime  of  life  are  es})ecially  subject  to 
the  infection,  and  Creoles  are  not  exempt.  Among  negroes  there  is  ftir  less 
susceptibility  to  the  disease  and  less  fatality  than  among  whites.  Billings 
suggests  that  negroes  may  have  had  a  mild  form  of  the  disease  in  infancy,  and 
mav  have  secured  an  apparent  immunity  in  tli.it  manner. 

Immunity. — Tlie  statement  is  often  made  tiiat  one  attack  renders  tlie  indi- 
vidual exempt  for  lifr  from  a  second.  While  tliis  is  true  in  the  vast  majority 
of  cases,  there  are  mauv  well -authenticated  instances  of  a  second  attack  occur- 
ring in  the  same  person  after  an  interval  of  years.  A  person  who  has  had 
one  attack  is  said  to  l)e  ''acclimated"  or  "  j^rotected."  These  expressions  do 
not  refer  to  those  wlio  have  escaped  the  disease  entirely. 

In  cities  where  yellow  fever  has  existed  for  a  long  time  in  endemic  form 
the  residents  acquire  immunity  U)  a  remarkable  extent,  so  that  the  disease  is 


454  YELLOW  FEVER. 

really  kept  in  force  by  infants  and  strang:ers  from  northern  climates,  who  are 
alike  unacclimated.  Thus,  of  55  nnaeclimated  physicians  who  went  to  Memphis 
to  labor  in  the  epidemic  of  1878,  54  contracted  yellow  fever  (Bemiss).  The 
immunity  or  acclimatization  is  lost  to  a  great  extent  by  subsequent  prolonged 
residence  in  a  northern  climate. 

Fear,  worry,  and  panics  favor  the  acquisition  of  the  disease  by  reducing 
vitality  and  resisting  power.  The  same  is  true  of  fatigue,  constipation, 
exj)()siire    to    a    hot   sun,   and    debauchery. 

Morbid  Anatomy. — In  mild  cases,  and  in  severe  cases  which  die  very 
early,  no  characteristic  lesions  are  found.  In  cases  of  ordinary  severity  post- 
mortem examination  reveals  hypersemia,  extravasation,  and  degeneration. 
Cadaveric  rigidity  occurs  promptly  and  is  well  marked.  The  important 
chansres  are   in   the  liver  and   o-astro-intestinal   mucous   membranes. 

The  liver  contains  less  blood  tiian  normal,  unless  death  has  occurred  very 
eai'ly,  when  it  is  congested.  It  is  usually  unaltered  in  size  and  is  friable. 
The  color  varies  from  pale  yellow  (cq/e  au  lait)  to  bright  yellow  or  almost  an 
orange  hue.  This  color  is  uniform  or  shaded  in  patches,  and  the  surface  may 
be  mottled  with  punctate  hfemorrhages.  The  liver  presents  the  changes  of 
parenchymatous  hepatitis.  The  hepatic  cells  in  certain  parts  are  filled  more 
or  less  completely  with  granular  matter  and  fat,  and  many  of  them  are  swollen 
and  fused,  and  their  nuclei  are  indistinct  or  absent.  In  other  portions  the 
cells  may  be  normal.  The  small  bile-ducts  are  filled  with  swollen  de";enerated 
epithelium.     The  gall-bladder  contains  a  very  little  dark  bile. 

The  skin. — The  icterus,  which  deepens  after  death,  and  is  regarded  as 
owing  to  altered  pigment,  which  colors  the  skin  in  a  certain  proportion  of 
cases,  appears  at  about  the  commencement  of  the  second  stage  of  the  disease. 
It  is  derived  from  the  red  blood-disks,  forming  hsematogenous  jaundice. 
Later,  at  the  end  of  the  second  period,  or  in  convalescence  in  a  smaller  num- 
ber of  cases,  the  color  of  the  skin  becomes  of  a  saffron,  mahogany,  or  even 
orange  hue,  and  the  urine  is  loaded  with  bile-pigmeut.  It  is  believed  by 
Feraud  and  others  that  this  form  of  jaundice  is  due  to  bile-pigment  contained 
in  excess  in  the  circulation.  It  affects  the  entire  body,  but  is  deepest  on  the 
arms  and  chest.  The  urine,  serous  fluids,  and  tissues  generally  are  stained 
yellow.  The  blood  is  dark,  coagulates  poorly,  and  many  red  corpuscles  are 
disintegrated.     It  quickly  decomposes. 

Scattered  throughout  the  entire  body,  especially  on  serous  and  mucous  sur- 
faces, are  small  hsemorrhagic  spots.  They  are  found  on  tlie  pleura,  peri- 
cardium, meninges,  between  the  muscles,  in  the  mucous  lining  of  the  gall-  and 
urinary  bladders,  and  in  the  stomach  and  intestines.  Petechia,  vesicles,  or 
large  irregular  ecchymotie  spots  are  also  found  on  the  skin,  especially  in 
dependent  portions  of  the  body.  Larger  hemorrhagic  infarctions  occur  some- 
times in  the  lungs  and  other  viscera.  The  heart-muscle  is  pale,  soft,  and  the 
seat  of  gramdar  and  fatty  degenerati(Mi.  The  spleen  is  not  enlarged,  but  is 
dark  and  frial)le. 

The  hidaeys  present  a  more  or  less  advanced  parenchymatous  nephritis. 


SY3fPrOMATOLOGY.  A'}~> 

There  is  cloudv  swelling  of  the  epitliclia  of  the  tubules  with  granular  fatty 
degeneration.  There  are  granular  easts  in  the  tubules.  The  whole  alinientarv 
canal  is  the  seat  of  acute  catarrh,  but  the  gastric  mucous  wall  especially  is  soft, 
turgid,  and  ecchymotic,  and  it  may  present  erosions  and  contain  "  black-vomit" 
material.     Similar  material  is  found  in  the  small  intestines. 

The  brain  is  hyperjemic,  especially  the  pons  and  medulla,  and  the  meninges 
are  congested.  Schmidt  describes  certain  degenerative  changes  in  the  sympa- 
thetic ganglia,  with  disappearance  of  the  nuclei  of  the  nerve-cells. 

Symptomatolog-y. — The  incubation  period  of  yellow  fever  lasts  from 
twenty-four  hours  to  six  days  :  it  may  c\cn  extend  over  ten  days.  It  is  short 
in  severe  epidemics. 

Stages. — The  disease  has  three  stages  :  I.  The  "  paroxysm,"  consisting  of 
a  cold  period,  followed  by  a  febrile  reaction;  II.  A  remission  or  "  stage  of 
calm  ;"   III.  A  urfemic  stage,  or  a  second  exacerbation  or  collapse. 

First  Stage. — The  invasion  is  in  all  cases  sudden,  and  it  may  occur  at  anv 
hour.  It  is  characterized  by  a  chill,  rigors,  frontal  headache,  vomiting,  lum- 
bar pains,  pains  in  the  calves  of  the  legs,  and  great  muscular  prostration. 
There  is  capillary  congestion,  and  the  patient  soon  acquires  a  typical  expres- 
sion, with  shining,  staring,  watery  eyes  and  congestive  cheeks  and  conjunc- 
tivae. There  is  photophobia.  There  may  be  excessive  sweating.  The  mind, 
as  a  rule,  is  clear,  delirium  being  exceptional. 

In  children  the  disease  often  begins  with  convulsions.  The  cold  period  is 
followed  by  one  of  pyrexia,  with  a  rapid  rise  of  temperature,  104°  or  105° 
F.  being  the  maximum  reached  in  twelve  or  eighteen  hours.  The  tempera- 
ture, as  iu  malarial  fever,  begins  to  rise  during  the  chill.  The  fever,  which  is 
seldom  very  high,  gradually  subsides  after  the  maximum  is  reached,  and  after 
three  to  five  days,  with  very  slight  remissions,  the  temperature  reaches  the 
normal  degree.  There  is  continued  vomiting,  first  of  nuicus,  then  of  bile, 
sometimes  of  blood.  The  stomach  is  intensely  irritable,  and  the  vomiting  is 
of  the  projectile  type.  Pressure  over  the  epigastrium  excites  emesis.  The 
bowels  are  costive.  The  gums  are  sore  and  swollen,  the  mouth  is  dry,  tiie 
tongue  is  red  at  the  tip,  and  is  often  narrow.  The  skin  may  be  dry  and  hot 
tiiroughout  the  febrile  stage,  or  it  may  be  bathed  in  a  profuse  perspiration, 
which  emits  a  peculiar  sickly,  disagreeable  odor. 

There  is  scanty  acid  urine,  which  shows  a  trace  of  albumin  on  tiic  third 
day.  There  are  great  restlessness  and  ])()ssibly  delirium.  On  the  third  or 
fourth  day  the  conjiinctivte,  and  later  the  entin;  body,  begin  to  show  an 
icteroid  hue.  The  pulse  is  slow  iu  proportion  to  the  fever,  seldom  rising 
above  110,  and  fre(jucntly  kcc])ing  within  100.  It  is  often  described  as 
"gaseous,"  or  highly  compressible  and  feeble.  It  may  grow  slower  before  the 
fever  declines.  Sometimes  the  cold  stage  is  inappreciable,  and  the  disease 
seems  to  commence  with  the  fever.  The  symj)loms  thus  far  deseril)ed  con- 
stitute the  "  ])aroxysm."  On  the  fouitli  or  lilth  day  the  fever  and  other 
symj>toms  abate  and   the  "stage  of  calm  "   is  reached. 

Second  Stage. — The  temperatur<',   having  attained   th<;   noiniai   degree    by 


456  YELLOW  FEVER. 

lysis,  may  become  subnormal  and  the  patient  feels  greatly  relieved.  In  mild 
cases  convalescence  begins  from  this  time.  The  "calm  stage"  rarely  exceeds 
two  days  in  duration,  and  frequently  lasts  but  a  few  hours,  when  the  patient 
becomes  much  worse  again,  grows  deeply  jaundiced,  and  passes  into  the  third 
stage.  In  severe  cases  there  is  sometimes  a  reactionary  fever  of  remittent 
type  and  irregular  duration  (Sternberg).  The  urine  is  diminished  in  amount 
and  there  is  albuminuria. 

Thhxl  Stage. — The  striking  features  of  this  stage  are  tendencies  to  haem- 
orrhages from  all  the  mucous  surfaces  and  to  complete  suppression  of  urine. 
The  temperature  either  rises  again  for  a  day  to  103°  or  104°  F.,  or  it  remains 
normal  while  symptoms  of  uraemia  develop.  The  pulse-rate  may  be  abnor- 
mally slow,  falling  sometimes  to  40  per  minute.  Bleeding  occurs  uniformly 
from  the  stomach  as  "  black  vomit,"  and  in  addition  it  may  take  place  from  any 
other  mucous  surface  or  into  the  skin.  The  '^ black  vomit"  is  present  in  about 
one-third  of  the  fatal  cases,  and  is  due  to  passive  haemorrhage,  but  is  not  by 
itself  patliognomonic  of  yellow  fever,  as  it  may  occur  in  other  affections.  The 
stomach  at  first  ejects  whatever  food  it  may  contain,  then  mucus  tinged  with 
bile,  and  finally  brown  or  black  semifluid  acid  material  resembling  coffee- 
grounds,  and  consisting  of  red  blood-corpuscles,  pigment-granules,  degenerated 
mucous  and  epithelial  cells  and  leucocytes,  fatty  matter,  and  serous  fluid.  The 
acid  gastric  juice,  acting  on  the  blood-pigment,  makes  it  dark  brown  or  black. 
The  quantity  of  this  fluid  ejected  varies  from  a  few  drachms  to  several  pints. 
It  is  acrid  and  irritates  the  fauces  and  mouth.  The  blood,  altered  in  compo- 
sition, oozes  from  the  capillary  walls  of  the  congested  mucous  membrane  of  the 
stomach.  The  fluid  is  not  always  vomited,  but  in  fatal  cases  it  is  very  excep- 
tional not  to  find  it  accumulated  in  the  stomach.  The  intestines  mav  be  the 
seat  of  similar  haemorrhages,  giving  black  diarrhceal  stools.  The  swollen  gums 
bleed  readily,  and  there  may  be  epistaxis.  Rarely  there  is  haemorrhage  from 
the  respiratory  tract,  the  nose,  the  ear,  and  the  urethra.  Females  who  are 
capable  of  menstruation  bleed  profusely  from  the  vagina  and  uterus.  Dur- 
ing pregnancy  yellow  fever  causes  miscarriage.  The  jaundice  deepens  and  the 
skin  becomes  of  a  dark  olive  or  mahogany  hue.  If  there  be  perspiration,  it 
stains  the  linen  yellow  and  emits  a  cadaveric  odor.  The  urine  becomes  more 
and  more  scanty.  It  is  acid,  of  high  specific  gravity,  and  it  may  be  stained 
by  the  altered  blood-pigment.  The  chlorides  are  diminished.  It  contains 
granular  and  hyaline  casts,  and  its  suppression  adds  uraemia  to  the  existing 
toxaemia  of  the  yellow  fever.  Sometimes  cutaneous  eruptions  appear,  such  as 
roseola,  pustules,  or  herpes  labialis. 

Exceptional  cases  arc  those  (a)  in  which  the  cold  period  is  omitted,  and 
fever  inaugurates  the  first  stage ;  (6)  cases  in  which  no  fever  follows  the  cold 
period,  or  the  febrile  reaction  is  delayed,  while  the  patient  becomes  stupid  or 
semi-comatose,  and  the  skin  is  congested  and  livid,  the  pulse  being  extremely 
feeble,  albuminuria  occurring  on  the  first  day,  and  the  patients  dying  within 
three  days;  (c)  cases  commencing  with  delirium  or  maniacal  excitement. 

Should  recovery  take  place,  the  jaundice  continues  for  several  days,  grad- 


DURATION  AND    TEJiMINATTONS.— DIAGNOSIS.  457 

iially  fading  out.  If  the  case  be  fatal,  the  jaundice  persists  after  death. 
Other  expressions  are  used  in  describing  various  types  of  yellow  fever  in 
which  certain  symptoms  predominate,  such  as  ataxic,  algid,  adynamic,  con- 
gestive, etc. 

Duration  and  Terminations. — In  a  violent  epidemic  a  patient  may  die 
suddenly  from  et)llapse  within  the  first  few  hours  of  the  disease,  being  stricken 
down  while  walking  or  at  work.  Death  is  most  apt  to  take  place  from  the 
third  to  the  fifth  day.  Relapses  are  infrequent,  but  they  may  occur.  If  the 
patient  do  not  improve  or  ^lic  before  the  fourth  or  fifth  day,  he  passes  into  a 
typical  typhoid  state,  with  sordes,  hard,  dry,  black  tongue,  muttering  delirium, 
diarrhoea,  petechise  on  the  skin  with  large  ecchymotic  patches,  extreme  albu- 
minuria, increased  epigastric  tenderness,  black  vomit,  and  finally  suppression 
of  urine,  followed  by  convulsions  or  coma  and  death. 

In  cases  which  recover  the  average  duration  of  the  disease  is  six  days. 
Death  occurs  from  the  poison  of  the  disease  itself,  exhaustion,  urcemia,  or 
black  vomit.  It  is  not  very  common  for  patients  to  die  from  the  hemorrhage 
alone,  though  it  should  always  be  borne  in  mind  that  death  may  result  sud- 
denly from  this  or  other  cause  at  almost  any  period  of  the  disease.  It  may 
occur  in  syncope  after  violent  maniacal  excitement. 

Complications. — There  are  no  special  complications  of  yellow  fever.  It 
may  exist  in  the  course  of  various  chronic  diseases.  The  black  vomit  and 
jaundice  in  many  cases  do  not  appear  at  all,  but  when  present  they  are  symp- 
toms rather  than  complications. 

Sequelae. — The  sequelae  of  yellow  fever  are  few.  Convalescence,  always 
slow  except  in  the  mildest  cases,  may  be  further  retai-ded  by  general  furuncu- 
losis,  suppurative  parotitis,  hepatitis,  or  by  a  very  weak  and  irritable  stomach 
and  diarrhoea.  Errors  in  diet  have  been  known  to  produce  fatal  gastric  hem- 
orrhage two  or  three  weeks  after  establishment  of  convalescence.  The  heart 
is  apt  to  be  feeble,  and  reparative  and  nutritive  processes  proceed  slowly. 
Phlebitis  and  thrombosis  of  the  femoral  vein  sometimes  follow.  The  stomach 
often  remains  irritable  for  a  long  time.  Relap.ses  occasionally  occur  during 
early  convalescence. 

Diag-nosis. — The  diagnosis  of  yellow  fever  is  based  upon  the  following 
features:  its  portability  by  fomites,  the  sudden  invasion  by  chill  and  rapid 
rise  of  temperature,  with  a  slow  ])ulse,  pains  in  the  forehead,  lumbar  region, 
and  calves,  tenderness  over  the  epigastrium,  redness  of  the  eyes,  excessive  gas- 
tric irritability,  black  vomit,  jaundice,  and  diminished  uiine  with  albuminuria. 
Typical  cases  presenting  all  these  features  are  unmistakable.  In  mild  cases  a 
correct  diagnosis  may  be  difficult.  In  any  doubtful  case  occurring  in  a  mala- 
rial district  at  the  commencement  of  an  epidemic  of  yellow  fever  it  is  well  to 
give  a  large  dose  of  quinine  with  a  purge,  and  favor  free  diaphoresis  by  hot 
diluent  drinks  and  a  warm  bath.  If  the  tem]>orature  yield  to  these  measures 
and  the  patient  improve,  he  has  not  taken  yellow  fever.  The  jaundic<>  itself 
is  a  very  misleading  diagnostic  featiu'c,  for  it  is  oflen  absent  in  yellow  fever, 
and  may  be  present  in  malignant  types  of  malarial  fever.     It  may  occur  only 


458  YELLOW  FEVER. 

as  a  post-mortem  pigmentation  in  yellow  fever,  and  even  in  the  severe  eases  it 
is  not  common  before  the  fourth  or  even  fifth  day.  ]\Iild  cases  and  the  earlier 
cases  of  an  epidemic  may  be  confounded  with  relapsing  fever,  severe  malai'ial 
fevers,  such  as  bilious  remittent  or  pernicious  malarial  fever,  acute  yellow 
atrophv  of  the  liver,  or  jaundice  of  local  hepatic  origin  attended  by  fever. 

Relapsing  fever  has  a  typical  spirillum  found  in  the  blood,  is  non-con- 
tagious, the  spleen  is  enlarged,  there  is  no  black  vomit,  there  is  a  typical 
relapse,  and  both  temperature  and  pulse  are  higher  than   in  yellow  fever. 

Malarial  fevers  are  non-portable,  are  controlled  by  quinine,  the  spleen  is 
enlarged,  the  fever  is  distinctly  periodic,  either  remittent  or  intermittent,  albu- 
minuria is  much  less  frequent,  and  one  attack  of  the  fever  favors  subsequent 
ones. 

In  bilious  remittent  fever  there  are  usually  several  paroxysms  instead  of 
one ;  the  remission  commonly  occurs  abruptly,  within  twenty-four  hours 
instead  of  upon  the  fourth  day  ;  the  tongue  is  coated  heavily,  and  is  broad, 
flabby,  and  indented  by  the  teeth,  instead  of  sharp,  dry,  and  pointed ;  the 
spleen  is  large;  the  splenic  area  is  tender;  delirium  is  more  common;  and 
copious  vomiting  of  bile  occurs,  in  distinction  from  the  mucus  and  black  vomit 
of  yellow  fever.  Albuminuria  is  rare,  and  the  ague  is  more  apt  to  occur  in 
inland  rural  districts  than  in  seaport  towns  and  cities.  Free  pigment  and  the 
malarial  plasmodium  may  be  found  in  the  blood.  Death,  if  it  takes  place, 
comes  earlier  than  in  yellow  fever. 

Hsemorrhagic  remittent  malarial  fever,  accompanied  by  jaundice,  sometimes 
resembles  yellow  fever  quite  closely,  but  previous  attacks  of  ordinary  ague 
will  have  occurred,  the  jaundice  appears  very  early,  and  the  symptoms  fluctu- 
ate with  the  temperature,  and  melanuria  appears  with  each  paroxysm. 

Phosphorus-poisoning  has  some  features  in  common  with  yellow  fever, 
but  the  odor  of  the  drug  is  obtained  in  the  breath  and  traces  of  poison  may 
be  found  in  the  ejecta. 

In  acute  yellow  atrophy,  which  is  non-portable  and  not  epidemic,  the 
spleen  is  enlarged,  the  liver  is  reduced  in  size,  black  vomit  is  absent,  and  the 
disease  begins  slowly  without  fever  or  pain. 

In  local  jaundice  with  pyrexia  difficulty  in  diagnosis  may  arise,  but  care- 
ful attention  to  the  special  diagnostic  symptoms  of  yellow  fever  above  enume- 
rated will  seldom  fail  to  decide  the  case. 

Prognosis. — The  prognosis  depends  upon  the  severity  of  the  epidemic. 
As  in  many  other  epidemics,  the  maximum  mortality  in  yellow  fever  is 
usually  attained  in  a  middle  period,  the  earlier  and  later  cases  being  less 
severe.  The  hospital  mortality  is  always  worse  than  that  of  private  cases. 
It  is  seldom  less  than  20  per  cent,  among  unacclimated  adults,  and  it  may 
exceed  50  per  cent.  This  is  in  part  due  to  the  fact  that  the  cases  come  under 
treatment  late,  many  being  brought  in  moribund.  In  mild  epidemics  1  patient 
in  every  15  or  20  dies;  in  severe  epidemics  1  in  3  dies.  In  the  epidemic  of 
1878,  36,000  cases  occurred  in  Louisiana  witii  a  mortality  of  16.66  per  cent. 
(Bemiss),  and  in  New  Orleans  the  mortality  at  the  Charity  Hospital  was  50 


TREA  TMEXT.  459 

per  cent.     Among  the  fatal  cases  nearly  three-fourths  of  the  deaths  occur 
during  the  first  week. 

The  prognosis  is  particularly  bad — (1)  if  the  initial  paroxysm  is  unduly 
intense;  (2)  if  severe  gastric  irritability  is  persistent;  (3)  if  black  vomit 
occurs,  but  especially  if  there  are  passive  haemorrhages  from  various  mucous 
surfaces ;  (4)  if  albuminuria  increases  and  the  volume  of  urine  diminishes ; 
(5)  if  jaundice  appears  early  and  is  intense;  (6)  if  patients  have  been  greatly 
worried  or  fatigued,  or  if  they  are  suffering  from  inanition  or  cachexite ;  (7) 
in  pregnancy  and  the  puerperal  state;  (8)  if  capillary  congestion  of  the  skin  is 
excessive  in  the  first  stage;  (9)  if  there  are  delirium  and  irregular  pulse  and 
respiration. 

C'omplete  suppression  of  urine  is  more  fatal  than  black  vomit.  The  com- 
bination of  black  vomit  and  complete  suppression  of  urine  is  certainly  fatal. 
If  necessity  for  removing  the  patient  arise  after  the  attack  has  begun,  the 
prognosis  is  rendered  worse  thereby.  Prognosis  is  bad  in  certain  rare  cases 
in  which  the  earliest  symptom  is  delirium  or  stupor. 

Prognosis  is  fav^orable  when  the  gastric  irritability  and  the  amount  "of 
albumin  in  the  urine  diminish.  Ordinary  bilious  vomiting  is  not  an  unfavor- 
able sign. 

The  disease  is  more  fatal  among  men  than  among  women  and  children, 
and  more  fatal  among  alcoholic  and  plethoric  subjects. 

When  the  temperature  remains  below  103.5°  during  the  paroxysm  the 
course  of  the  disease  will  probably  be  mild.  If  a  certain  locality  has  enjoyed 
long  immunity  from  yellow  fever,  the  epidemic  is  apt  to  be  severe,  because 
there  will  be  more  unprotected  persons  exposed  to  the  disease. 

Treatment. — While  there  is  no  specific  for  yellow  fever,  which  is  a  self- 
limited  disease,  many  lives  may  be  saved  by  prompt  and  vigorous  measures. 
There  is  no  disease  of  which  this  can  be  said  with  greater  emphasis,  and  as 
much  depends  upon  the  faithfulness  and  efficiency  of  a  thoroughly  trained 
nurse  as  upon  the  physician.  .  ]Maintaining  the  patient's  courage  and  hope  is 
of  great  service. 

The  indications  for  treatment  are — 

I.  To  adopt  prophylactic  measures  by  rigid  quarantine,  etc. ; 
II.  To  keej)  the  patient  absolutely  quiet ; 

III.  To  control  the  emesis  and  prevent  the  suppression  of  urine ; 

IV.  To  support  the  strength  until  the  crisis  is  past. 

I.  Prophylaxis. — When  an  epidemic  breaks  out  all  ])crs()ns  whose  duty  does 
not  keep  them  with  the  sick  do  well  to  leave  the  infected  district  immediately. 
It  is  well  to  avoid  the  presence  of  fever-stricken  patients  when  suffering  from 
fatigue,  loss  of  food  or  sleep,  or  depressing  emotions, — all  of  which  factors  ren- 
der one  more  liai)le  to  the  disease.  Nurses  and  attendant:^  should  secure  all 
the  fn'sh  air  possible,  and  hospital  |)atieiits  are  often  best  treated  out  of  doors 
in  tents.  The  patient  should  be  (|uarantined,  ami  all  caic  nuist  be  taken  to 
prevent  the  distribution  (»i"  <lotiiiug,  bcilding,  or  any  ])ers()nal  elfccts  which 
have   not   Ikiii    iii(»st   tlioroiiglily  disinfected   by  strong    iicat,   fumigation,   or 


460  YIJLLOn"  FEVER. 

other  Dieasures.  The  disease  lias  been  transmitted  by  a  lock  of  hair  from  a 
diseased  patient,  and  frequently  through  the  medium  of  the  mails. 

Quarantine  based  merely  upon  a  time  limit  is  ineffectual,  and  it  should 
depend  rather  upon  the  perfection  of  sanitary  arrangements.  The  cardinal 
principles  involved  in  prophylaxis  during  any  epidemic  are  summed  up  in  the 
oft-quoted  words,  "  Isolation,  disinfection,  and  depopulation." 

As  in  the  case  of  cholera,  strict  sanitary  cordons  around  an  infected  area  as 
a  rule  prove  useless  and  practically  impossible,  and  prompt  depopulation,  with 
thorough  destruction  of  all  fomites,  is  both  more  effectual  and  more  humane. 
All  excreta  should  be  disinfected  and  afterward  buried,  although  their  infec- 
tive power  is  doubted  by  some  observers ;  and  Freire  advises  the  cremation 
of  the  bodies  of  those  dying  of  the  disease. 

If  yellow  fever  extends  to  a  ship  in  an  infected  port,  the  vessel  should  put 
to  sea  and  reach  a  healthy  port  as  speedily  as  possible,  when  the  crew  having 
been  isolated,  it  must  be  thoroughly  fumigated,  scraped,  cleaned,  and  painted. 

II.  Early  Treatment. — As  soon  as  the  diagnosis  of  yellow  fever  is  made  the 
])atient  must  be  put  to  bed  and  kept  from  visitors  or  excitement  of  any  kind. 
Cheerful  surroundings  and  abundant  fresh  air  are  most  important.  Medica- 
tion and  fluids  must  be  given  through  a  tube  or  with  a  teaspoon  to  avoid  rais- 
ing the  head.  The  bed  should  be  kept  clean  and  the  linen  changed  without 
moving  the  patient  unnecessarily  or  exposing  him  to  draughts.  A  bed-pan 
should  be  used,  and,  if  the  urine  cannot  be  voided  while  the  patient  is  recum- 
bent, it  is  better  to  use  a  catheter  than  to  let  him  run  the  risk  of  rising.  If 
the  patient  be  seen  very  early  and  indigestible  food  has  been  taken,  the  stomach 
should  be  unloaded  by  an  emetic  of  ipecac.  If  there  be  constipation,  a  laxative 
or  a  purgative  enema  should  be  given.  Excessive  purgation  is  to  be  avoided, 
although  it  is  a  very  common  domestic  practice  to  give  castor  oil  on  the  first 
day.  It  is  well  to  promote  diaphoresis  by  a  hot  mustard  foot-bath  ;  the 
patient  is  then  kept  covered  by  blankets,  and  is  given  a  hot  lemonade  or  hot 
alcoholic  drink.  The  neuralgic  pains  in  the  calves  and  back  are  relieved  by 
twenty  grains  of  quinine  |?er  rectum  (Bemiss).  Salol  in  five-grain  doses  every 
two  hours  is  sometimes  useful  for  its  favorable  action  in  the  intestine. 

III.  Treatment  of  Emesis  and  Suppression  of  Urine. — When  emesis  becomes 
severe  attempts  should  be  made  to  control  it  by  a  mustard  paste  over  the  epi- 
gastrium and  the  internal  adniinistration  of  any  of  the  following  :  dilute  hydro- 
cyanic acid;  cerium  oxalate;  cracked  ice;  light  acidulated  and  effervescing 
draughts,  or  plain  lime-water  in  frequent  half-ounce  doses;  cocaine  in  doses  of 
one-sixth  of  a  grain.  If  these  measure  fail,  it  is  best  to  let  the  stomach  have 
absolute  rest,  employ  the  rectum  for  subsequent  medication,  and  give  a  small  hy- 
podermic injection  of  morphine.  No  htemostatics  have  any  specific  control  over 
the  black  vomit  or  the  purj)ura,  and  no  unnecessary  medicine  should  be  given. 

With  evidence  of  suppression  of  urine  the  lumbar  region  should  be  cupped 
and  poulticed  or  covered  witii  a  large  mustard  paste  or  a  turpentine  stupe. 
The  effervescing  draughts  should  be  increased.  Apollinaris,  Seltzer,  Vichy, 
iced  champagne,  lemonade  with  bitartrate  of  potassium,  are  all  useful.     If  the 


TREA  TMEXT.  461 

stomach  will  not  tolerate  these  beverages,  a  pint  of  salt  water  should  be 
inject e<l  into  the  rectum  every  two  hours.  Digitalis,  camphor,  or  ammonia  in 
whiskey  may  be  given  per  rectum.  Diaphoresis  should  be  encouraged  in  every 
way  possible  without  too  much  disturbance  of  the  patient.  The  temperature 
seldom  demands  special  attention.  If  very  high  and  prolonged,  it  should  l)e 
controlled  by  frequently  sponging  the  body  with  equal  parts  of  alcohol  and 
water. 

IV.  Supporting  Treatment. — In  ordinary  cases  during  the  febrile  paroxysm 
it  is  best  to  give  no  food  at  all,  for  the  stomach  will  only  be  disturbed  by  it. 
In  cases  accompanied  by  great  prostration  the  immediate  administration  of 
stimulants  by  the  rectum  and  hypodermically  may  be  necessary.  If  extreme 
restlessness,  insomnia,  or  delirium  be  wearing  out  the  patient's  strength,  mor- 
phine should  be  given  hypodermically  or  opium,  sulphonal,  chloral,  or  bro- 
mides per  rectum. 

After  the  paroxysm  is  over  the  greatest  care  must  still  be  exercised  in 
regard  to  diet.  No  solid  food  should  be  given  for  ten  days  or  a  fortnight 
in  bad  cases.  At  first  teaspoonful  doses  may  be  given  of  peptonized  milk, 
koumyss,  or  iced  champagne,  followed  by  beef-juice,  and  later  by  nourishing 
broths  and  gruels.  Stimulating  or  nutrient  enemata  may  be  given  once  in  two 
hours.  They  should  be  injected  high  up  by  the  use  of  a  flexible  rubber  tube. 
A  few  drops  of  laudanum  will  often  secure  their  retention  if  the  rectum  prove 
irritable.  In  this  way  peptonized  milk,  beef  peptonoids,  brandy,  egg-albumin, 
etc.  are  given,  and  enough  is  absorbed  to  maintain  life  until  the  stomach  retains 
food.  Children  even  earlier  than  adults  usually  require  rectal  stimulation. 
Large  doses  of  opium  should  be  avoided  on  account  of  the  tendency  to  sup- 
pression of  urine. 

Exceptional  and  very  fatal  cases  are  those  in  which  no  reaction  follows  the 
initial  cold  stage.  For  these  it  is  recommended  to  give  hot  mustard  s})onge- 
baths  and  vigorous  stimulation.  Other  cases,  occurring  especially  among  the 
young,  show  violent  neurotic  symptoms  at  the  first,  such  as  convulsions,  delir- 
ium, with  alternate  flushing  and  pallor  of  the  face.  For  this  type  Bemiss 
advises  the  application  of  leeches  to  the  temples  or  back  of  the  neck,  cold 
applications  to  the  head,  calomel,  chloral  by  enema,  morphine  by  the  skin, 
and  the  inhalation  of  chloroform  if  the  convulsions  are  severe. 

Sternberg,  who  has  been  em])loyed  by  the  United  States  government  to 
.study  recent  epidemics  of  yellow  fever,  advocates  the  use  of  sodium  bicarbo- 
nate to  make  the  highly  acid  urine  neutral  or  alkaline,  and  thereby  diminish 
the  imminent  danger  of  nephritis  with  suppression,  lie  has  also  had  some 
success  with  the  internal  use  of  corrosive  sublimate. 

The  fact  that  epidemics  of  yellow  fever  are  arrested  by  frost  has  led  to  the 
experiment  of  treating  patients  by  surrounding  them  with  an  atmosphere  of 
artificially  cooled  air  (Garcia);  but,  as  might  be  expected  from  the  fact  that 
the  reduction  of  the  internal  body-temperature  to  any  marked  degree  is  incom- 
j>alible  with  maintenance  of  lifi',  this  treatment  has  yielded  discouraging  re- 
sults, besides  being  very  expensive*  and   uncomfortable  for  llic  patient. 


TETANUS. 

By  JAMES  T.  WHITTAKER. 


Tetanus  (rsrai'oc,  tscuo),  to  stretch)  ;  Trismus ;  Lockjaw ;  Opisthotonos 
{oTTcffdi,  backward,  ztivto,  to  stretch) ;  Starrkranipf,  Wundstarrkrampf  (Ger.), 
— a  grave,  often  exquisitely  acute,  infection,  caused  by  a  specific  bacillus,  the 
tetanus  bacillus,  introduced  through  a  wound  or  some  break  of  the  surface, 
characterized  by  excessively  heightened  reflex  under  the  action  of  toxines, 
wdiich  induce  spasmodic  contraction  of  the  voluntary  muscles,  first  and  espe- 
cially of  the  jaw  (trismus,  lockjaw),  face,  and  neck,  and  extensors  of  the  spine 
(opisthotonos),  of  short  duration,  often  of  rapidly  fatal  termination.  Among 
the  larger  animals  the  horse,  sheep,  and  goat  are  especially  liable  to  the 
disease. 

The  clinical  features  of  tetanus  are  so  coarse  and  obtrusive  as  to  have  been 
remarked  in  the  most  ancient  times.  Some  of  the  finest  descriptions  of  Aretseus 
were  based  upon  observations  of  tetanus.  Hippocrates  devoted  a  whole  section 
to  its  treatment,  ancl  certainly  appreciated  the  gravity  of  the  disease.  "  Such 
persons,"  he  says,  "  as  are  seized  with  tetanus  die  within  four  days,  or,  if  they 
pass  these,  they  recover."  Aretseus  declared  tetanus  to  be  a  spasm  of  an  exces- 
sively painful  nature,  very  swift  to  prove  fatal,  and  not  easy  to  be  removed. 
"  It  supervenes,"  he  declares,  "  on  the  wound  of  a  membrane  or  of  a  muscle 
or  about  punctured  nerves,  when,  for  the  most  part,  patients  die;  for  spasm  from 
a  wound  is  fatal."  ....  Women  are  more  disposed  than  men ;  children  are 
frequently  affected,  but  less  fatally.  "  In  all  the  varieties,"  he  says,  "  there  are 
pain  and  tension  of  the  tendons  and  spine  and  of  the  muscles  connected  with 
the  jaws  and  cheek,  so  that  the  jaws  could  not  easily  be  separated  even  with 
levers  or  a  wedge."  No  such  graphic  description  of  the  symptomatology  of 
the  disease  as  detailed  by  Aretseus  has  ever  since  been  written.  The  distor- 
tion and  suffering  are  so  great  as  to  make  the  spectacle  painful  even  to  the 
beholder.  *' The  physician,"  he  declares,  "has  no  power  over  the  disease;  he 
can  merely  sympathize.     This  is  the  great  misfortune  of  the  physician." 

Most  of  the  contributions  of  later  times  have  been  presented  by  the  sur- 
geons Laurent,  Larrey,  etc.  Curling  wrote  his  famous  treatise  on  tetanus 
(Jacksonian  Prize  Essay)  in  1834  ;  Rose  (E.)  made  the  most  valuable  clinical 
contribution  of  modern  times  to  the  Handbuch  der  AUgem.  u.  Specielle 
Cliirurgie,  Pitha  u.  Billroth,  Bd.  1,  Abtheil.  A.,  1870.  Nikolaier  discov- 
ered the  bacillus  of  tetanus  in   1885. 

Brieger  (1887)  obtained  from  sterilized  cultures  of  the  tetanus  bacillus  a 
toxine  which,  in   mice,  in  the  smallest  doses,  produced  the  typical  symptoms 

40.2 


ETIOLOdY.  463 

of  trismus  and  tetanus  with  fatal  termination.  Besides  this  body,  Briesrer 
eliminated  various  tox-albumins  with  specifie  properties. 

Etiology. — Tetanus  is  now  known  to  be  a  s])eeitic  disease.  It  arises  in  no 
case  spontaneously,  and  demands  for  its  development  a  break  of  the  surface 
through  which  its  specific  cause  may  be  introduced;  hence  tetanus  follows 
most  frequently  in  the  course  of  and  in  consequence  of  some  external  injury. 
Though  the  extent  and  severity  of  the  injury  stand  in  no  direct  relation  to  the 
disease,  the  seat  and  character  of  the  woinid  have  much  to  do  with  its  devel- 
opment. For,  while  tetanus  may  occur  in  consequence  of  any  kind  of  wound, 
it  does  occur  much  more  frequently  after  contused  wounds  with  penetration  of 
foreign  bodies.  It  is  therefore  very  frequent  after  gunshot  wounds,  and  is 
especially  frequent  in  wounds  of  the  extremities.  Wounds  of  nerves  are  also 
attended  with  special  liability. 

Tetanus  may  follow  a  lesion  as  trivial  as  the  extraction  of  a  tooth,  a  vene- 
section, the  sting  of  an  insect,  a  simple  scratch  of  the  surface,  the  application 
of  a  blister,  a  slight  wound  of  the  foot  as  from  a  nail  in  a  shoe.  It  occurs 
not  infrequently  in  the  newborn  from  lesions  of  the  umbilical  cord,  and  has 
been  repeatedly  observed  after  a  wound  of  the  cervix  uteri,  as  after  parturi- 
tion. The  intrusion  of  a  splinter  of  wood,  the  lodgment  of  a  fish-bone  in  the 
throat,  have  broken  the  surface  sufficiently  to  introduce  or  give  entrance  to  the 
cause  of  the  disease ;  but,  as  the  cause  conies  from  without,  tetanus  occurs  in 
the  great  majority  of  cases  in  wounds  of  the  extremities.  Curling  found 
wounds  on  the  extremities  in  111  of  128  cases,  and  Thamhaym  in  395  cases 
found  the  locality  of  the  injury  in  the  hand  and  finger  119  times. 

Though  the  frequency  of  tetanus  varies  at  different  times,  it  is  on  the  whole 
a  comparatively  rare  disease.  True,  Lind  saw  5  of  6  cases  of  amputation  die 
of  tetanus,  and  once  in  modern  times — namely,  at  the  battle  of  Lyon  in  1834 
— 12  of  277  wounded  died  of  the  disease.  The  experience  of  Blanc,  who  saw 
30  cases  in  810  wounded,  is  also  unusual.  More  in  accord  with  the  rule  is  the 
rarity  of  the  disease  in  the  Civil  War  in  America  and  the  Franco-Prussian  AVar, 
in  one  corps  of  which  there  were  observed  but  45  cases  among  24,262  sick  and 
7182  wounded. 

In  civil  life  the  disease  is  still  more  rare.  Thus,  at  Guy's  Hospital  in 
thirty-two  years  there  occurred  but  1  case  of  tetanus  to  1570  patients;  in 
Vienna  in  ten  years,  but  1  case  to  4798  patients.  Rose  states  that  the  mortal- 
ity of  tetanus  in  Berlin  was  but  .04  per  cent.,  and  this  included  266  cases  in 
newborn  infants. 

The  di.sea.se  is  most  frequent  in  hot  countries.  Aside  from  attack  of  the 
newborn,  the  period  of  greatest  liability  is  between  ten  and  thirty. 

The  fact  that  the  disease  oc(aM's  after  minute,  almost  undiscoverable,  injuries 
as  readily  as  after  the  most  extensive  lesions,  long  ago  excited  susj)icioji  of  its 
infectious  nature.  Carle  and  Rattone  (1881)  furnished  the  first  proof  of  coni- 
municability  of  the  disease  by  the  inoculation  of  rabbits  with  pus  from  the 
wound  in  a  case  of  human  tetanus.  Nicolaicr  in  the  following  year  discovered 
widely  disseminated   in  all    kinds  of  earthy  matter  bacilli   which,  introduced 


464  TETANUS. 

subcutaneoiisly  into  mice,  guinea-pigs,  and  rabbits,  produced  typical  trismus 
and  tetanus  with  fatal  termination.  Roseubach  in  the  next  year  (1886)  dem- 
onstrated the  tetanus  bacillus  for  the  first  time  in  man,  and  a  number  of  com- 
petent observers  confirmed  these  demonstrations  in  other  cases,  including 
tetanus  neonatorum  (Beumer,  Piper),  including  also  castration  tetanus  and 
tetanus  traumaticus  in  animals  (Bonome).  Thus  was  established  the  genetic 
relation  to  the  disease  of  the  bacillus  of  Nicolaier. 

The  tetanus  bacillus  is  a  delicate  rod,  a  little  longer  than  the  bacillus  of 
mouse  septicaemia.  It  occurs  in  irregular  masses  iu  the  aifected  tissue,  and  is 
recognized  by  the  characteristic  development  of  its  spores.  One  end  of  the 
bacillus  swells  to  show  an  oval,  sharply-defined,  shining  spore,  and  presents  the 
appearance  of  clock  bell-strikers,  drumsticks,  or,  better,  pins.  This  spore  for- 
mation occurs  in  great  abundance  in  the  body  of  the  animal  as  well  as  in 
artificial  culture.  Tiie  bacilli  are  easily  colored  with  methyl-blue  and  fuchsine. 
Artificial  culture  is  difficult.  The  bacillus  is  a  strict — l.  e.  an  obligate — anae- 
robe, so  that  in  artificial  culture  particles  of  infected  matter  must  be  introduced 
into  the  deeper  layers  of  blood-serum  to  secure  growth.  The  culture  is  so 
commonly  contaminated  as  to  often  require  subsequent  separation  to  obtain  it 
pure. 

The  bacilli  and  spores  of  tetanus  are  so  widely  disseminated  in  soil  and 
dust  as  to  be  almost  ubiquitous.  They  abound  most  on  the  surface  of  inhab- 
ited soil,  and  are  not  entirely  absent  in  uncontaminated  virgin  soil.  The 
rubbish  and  dust  of  sti'eets  and  houses  are  soils  of  predilection.  The  wide 
dissemination  of  the  parasites  accounts  for  the  cases  of  apparent  spontaneous 
or  idiopathic  tetanus,  while  the  fact  that  the  free  access  of  oxygen  prevents  its 
growth  furnishes  explanation  of  the  comparative  rarity  of  the  disease  and 
greater  liability  in  case  of  penetrating  wounds. 

The  tetanus  spores  found  in  the  earth  develop  virulent  cultures  upon  serum 
in  the  course  of  sixteen  days.  Of  23  soil-tests  taken  in  Copenhagen,  16  proved 
virulent  in  the  inoculation  of  animals ;  7  tests  taken  at  a  depth  of  two  to  four 
feet  all  produced  tetanus ;  4  of  5  soil-tests,  taken  from  gardens  outside  of  the 
city,  showed  no  spores  and  produced  no  infection.  The  bacillus  is  innocuous  in 
the  stomach. 

In  an  examination  of  25  specimens  of  earth  Verhoggen  and  Baert  found 
the  genuine  tetanus  bacillus  15  times,  demonstrated  in  all  cases  by  inoculation. 
The  bacilkis  may  not,  however,  be  demonstrated  in  the  blood.  The  injection 
of  the  substance  of  the  spinal  cord  of  animals  dead  of  tetanus  produced  tetanus 
in  other  animals  only  when  introduced  under  the  dura,  and  never  when  intro- 
duced under  the  skin.  The  same  results  were  observed  with  the  use  of 
strychnine,  which  lias  much  the  same  effect  as  the  poison  of  tetanus.  The  dis- 
ease is  sometimes  conveyed  by  contact  with  horses  affected  with  tetanus,  though 
the  bacillus  is  found  much  more  frequently  in  the  soil  than  in  the  body  of 
animals.  Tureina  demonstrated  in  the  dust  of  the  floor  of  three  wards  of  a 
military  hospital,  as  well  as  in  the  dormitories,  the  presence  of  the  tetanus 
bacillus.     The  demonstration  was  made  by  means  of  the  inoculation  of  rabbits. 


ETIOLOGY.  4()5 

Dor  inoculated  rabbits  with  the  cerebro-spinal  fiiiid  of  a  man  dead  of  tetanus. 
The  animals  quickly  sueeumbed  without  showing  any  pronounced  picture  of 
tetaiuis.  Pure  cultures  were  made  with  the  tetanus  bacillus  obtained  from  the 
spinal  cord  of  these  animals.  Rabbits  inoculated  with  these  cultures  showed 
the  distinct  picture  of  true  tetanus.  The  bacilli  perish  very  rapidly  after  the 
death  of  the  patient,  hence  the  dithculty  of  their  detection.  Pure  cultures  are 
best  obtained  by  great  dilution  in  sterilized  water  and  stroke  inoculations  of 
the  serum  of  horses'  and  sheep's  blood. 

Brieger  demonstrated  the  presence  of  tetanine  both  by  chemical  analysis  and 
physiological  experiment.  Particles  from  an  infiltrated  arm  whieh  showed, 
under  the  microscope,  tetanus  bacilli,  other  long  bacilli,  sta]>hyl()cocci,  and 
streptococci,  were  introduced  untler  the  skin  of  mice,  guiuea-])igs,  and  rabbits, 
with  the  result  that  tetanus  occurred  in  every  case.  A  dog  j)roved  refractory 
both  to  this  substance  and  to  the  injection  of  tetanine.  A  large  abscess 
developed  in  a  horse.  Injections  of  large  doses  of  tetanine  produced  long, 
persistent,  violent  muscular  contractions,  but  the  rigidity  characteristic  of 
tetanus  in  the  horse  did  not  develo]).  Beunier  first  succeeded  in  producing 
the  characteristic  picture  of  tetanus  by  the  inoculation  of  particles  taken  from 
a  wound  at  the  umbilicus  in  a  child  dead  of  trisnuis  neonatorum.  The  denuju- 
stration  was  thus  offered  that  trismus  and  tetanus  in  the  newborn  may  be  no 
longer  looked  upon  as  a  neurosis,  but  nnist  be  regarded  as  a  traumatic  infec- 
tion. Kischensky  examined  three  cases  of  tetanus  neonatorum  in  consequence 
of  an  omphalitis.  Inoculation  of  the  pus  produced  tetanus  in  one  case.  In  all 
three  cases  the  streptococcus  was  found  in  the  pus,  and  in  one  case  it  was  also 
found  in  the  internal  organs.  Nissen  succeeded  in  demonstrating  toxines  of 
like  effect  in  the  circulating  blood  of  a  patient  affected  with  tetanus.  The 
blood,  withdrawn  by  venesection  twenty  mimites  before  death,  showed  itself 
free  of  tetanus  germs  in  agar  cultures,  but  the  injection  of  six  mice  with  but 
.03  ccm.  of  blood-serum  produced  a  fatal  tetanus  within  a  few  hours,  while 
other  mice  injected  with  the  blood-serum  of  healthy  or  n(m-tetanic  men 
remained  unaffected. 

Pestana  concludes  that  the  poison  of  tetanus  is  absorbed  by  the  blood,  and 
is  thence  taken  up  by  and  retained  in  the  lungs,  the  sj)leen,  the  kidneys,  and, 
above  all,  the  liver.  The  toxine  is  conveyed  by  the  urine  in  imj)erceptible 
quantities.  It  can  be  demonstrated  in  nerve-  and  muscle-substance.  Faber 
secured  a  filtrate,  by  means  of  Chamberland's  filter,  entirely  free  of  bacteria 
— a"  sterile,  clear,  yellowish,  nearly  alkaline  fluid  of  e(jual  virulence  with  the 
culture-soil  itself.  Inoculation  of  this  substance  is  followed  without  local 
sign.s — /,  e.  spasms — by  general  tetanus  which  begins  with  trisnuis.  The 
tetanus  shows  itself  sooner  than  after  infectiou.  The  filtrate  loses  its  virulence 
entirely  after  heating  for  five  minutes  at  0")°  ('.  luti-oduccd  into  the  aliment- 
ary canal,  it  has  no  poisonous  elle<'t. 

Kitasato  observed  that  the  filtrate  jjerfcctly  free  of  germs  pi-odueed  the 
same  tetanic  effect  as  the  culture  of  tetanus  bacilli  ;  lieiuie  tetamis  is  not  a 
question  of  infection,  but  of  intoxication  by  a  specific  product  of  the  tetanus 

Vol.  I.— .'.0 


466  TETANUS. 

bacillu.'-.  Of  the  auiiual.s  i'X])erinioiit('d  upon,  tlu'  most  sensitive  were  guinea- 
pigs,  then  miee,  then  rabbits.  Tetanus  sometimes  sliows  itself  at  once,  at  tiie 
latest  on  the  third  day.  The  inoculation  of  organs  of  animals  dead  of  tetanus 
into  other  animals  remained  without  effect,  but  the  inocidation  of  blood  or 
transudations  from  the  chest-cavity,  though  free  of  germs,  always  produced 
tetanus  in  Juice.  The  tetanus  poison  therefore  penetrates  to  the  blood  and  pro- 
duces here  its  toxic  effect.  A  filtrate  exposed  to  tlaylight  at  a  window  loses 
its  virulence  in  the  course  of  several  weeks,  but  M^hen  kept  in  a  dark  room  it 
is,  after  three  hundred  days,  as  virulent  as  when  fresh.  Direct  sunlight 
absolutely  destroys  the  poison  of  tetanus  in  fifteen  to  eighteen  hours.  Dilu- 
tions witli   water  do  not  affect  it. 

Morbid  Anatomy. — Tetanus  shows  no  distinct  and  definite  lesions.  The 
t^use  of  the  disease  often  disappears  to  leave  no  trace,  and,  since  this  cause 
has  been  determined  to  be  of  chemical  nature,  questions  of  morbid  anatomy 
have  lost  interest.  I^oc^khart  (larke  mentions  the  discovery  of  areas  of  fluid 
or  of  granular  disintegration  in  the  gray  matter  and  in  the  white  columns 
of  the  spinal  cord.  Coates  found  the  same  appearances  in  the  bulb  and  the 
pons.  Dickinson  looked  upon  these  changes  as  exudations.  Recent  necro})- 
sies  show  extensive  hypersemia,  which  in  the  course  of  time  entirely  fades 
away. 

Bruscattini  studied  the  condition  of  the  different  parts  of  the  organism 
after  inoculation.  He  made  inoculations  witli  emulsions  of  the  central 
nervous  system,  kidneys,  liver,  blood.  The  animals  having  been  killed 
when  the  sym})toms  were  at  their  height,  the  blood  and  kidneys  were  found 
virulent,  the  liver  and  suprarenal  capsules  innocent.  The  poison  is  dissemi- 
nated gradually  along  the  course  of  the  nerve-substance,  and  rather  in  ascend- 
ing than  descending  direction,  whether  it  be  injected  directly,  subdurally,  or 
subcutaneously,  after  the  manner  of  the  })oison  of  hydrophobia. 

Symptomatolog-y. — The  period  of  incubation  varies  from  one  to  two 
weeks.  Of  the  75  cases  recorded  by  Faber  observed  in  the  course  of  thirty- 
five  years,  the  period  of  incubation  could  be  accurately  established  in  but  64. 
In  74  per  cent,  of  these  cases  it  ranged  from  seven  to  eleven  days,  never  less 
than  four  or  more  than  twenty-two  days.  In  11  of  these  75  cases  no  contact 
with  tetanus  could  be  observed  ;  28  of  the  remaining  64  cases  were  infected 
by  the  soil,  11  by  contagion  in  the  hospital. 

The  disease  begins,  as  a  rule,  with  spasm  of  the  muscles  of  mastication. 
Contraction  of  the  masseters  locks  the  jaws  to  produce  the  condition  known 
as  trismus,  lockjaw.  Contraction  of  the  muscles  of  the  neck  occurs  at  the 
same  time  or  may  ])recede  the  conti-action  of  the  jaws.  Rose  delares  that 
the  contraction  of  the  masseters  may  be  felt  by  the  insertion  of  the  finger 
within  the  mouth,  antl  that  tiie  stiffness  of  the  muscles  of  the  back  of  the 
neck  is  best  recognized,  as  in  cerebro-s])inal  meningitis,  by  attempts  to  lift 
the  body  by  the  head.  The  affection  of  the  muscles  of  the  face  soon  ])ro- 
duces  a  pecidiar  physiognomy.  The  lips  are  usually  stretched  over  the  closed 
teeth  to  prcMluce  the  characteristic  smile,  the  riaus  .iardonicus,  so  graj)hicaily 


<l(>scribe(l  bv  Ilippocratcs.  Faj^p'  sju-aks  of  tlu>  case  of  a  *;irl  who  was  rcpri- 
maiKlod  l)v  licr  mother  on  account  of  a  siiigiihir  tjrinnin*;'  expression  of  the 
ia(^e,  over  which  she  had,  of  course,  no  control.  This  alteration  of  the  })hvsi- 
((•rnoniy  gives  to  the  patient  the  a])j)earan('c  of  ap-.  ^^n•r  savs  a  man  a^ed 
twentv-six  was  taken   for  sixty. 

The  disea.se  begins  usually  mildly  and  increases  gradually  and  i)rogressivi'ly. 
There  is,  iu  association  with  the  stiffness  of  the  neck  or  diminished  mobilitv 
of  the  jaw,  some  difficulty  of  deglutition,  'i'he  muscles  are  affected  from  ai)ove 
downward.  The  spasm  extends  to  involve  the  muscles  of  the  back.  Impli- 
<*ation  of  the  groups  of  great  muscles  in  the  spine  soon  distorts  the  bod  v.  The 
whole  trunk  is  stiffened  like  a  statue  (orthotonos),  or  is  moiv  frequently  arched 
with  its  convexity  upward  (o])isthotonos).  It  is  said  to  be  sometimes  arched 
ibrward  (emprosthotonos),  or  laterally  (|)leurosthotonos).  The  forearms  and 
hands  are  spared  for  a  long  time.  Motion,  either  active  or  passive,  is  soon 
iidiibited  or  lost  altogether  under  the  board-like  induration  of  the  nniscles. 
During  these  states  of  rigidity  convulsive  attacks  occur  with  .shocks  like 
.strokes  of  lightning.  They  show  themselves  iu  consequence  of  effort,  even  of 
invohnitary  effort,  (^r  as  the  result  of  any  outside  irritation,  and  express  the 
intense  reflex  excitability  of  the  spinal  cord.  In  the  intei-val  the  body  assumes 
\\\^i  position  of  rigidity  Irom  which  it  has  been  distorted  by  the  violence  of  the 
spasm.  The  suffering  of  the  j)atient  at  this  time  is  indesca-ibable.  The  sjiasms 
are  attended  with  excruciating  ]>ain.  The  mind  is  pei'fcctly  clear,  but  is  weak 
from  loss  of  sleep  and  anxiety.  The  ])atient  may  not  satisfy  either  hunger  or 
thirst  on  account  of  the  loi-king  of  flic  jaws.  The  arching  of  the  body  from 
(contraction  of  the  muscles  of  the  spine  (o})isthot()nos)  ])rcvcnts  a  proper  decu- 
l)itus.  Individual  muscles,  es])ecially  the  recti  abdominis,  have  actually  rup- 
tured under  the  ])owerful  contracction,  to  discharge  masses  of  blood  at  their 
<livided  ends.  Difficulty  of  breathing,  cyanosis,  a  sense  of  distress  and  danger, 
with  lancinating  pains  at  the  bottom  of  the  chest,  indicate  the  sj)asmodic  con- 
traction of  the  diaphragm.  Fever  may  Ix;  entirely  al)s(Mit.  There  is  genei-ally 
some  elevation  of"  temperature,  which  is  liable  to  sudden  exaggeration,  often 
without  discoverable  (cause,  probably  due  to  the  influence  of  the  uervoas  sys- 
tem. Extreme  elevations  of  temjM'rature  to  110°  or  112°  l'\  aic  pre-agonal. 
Sometimes  there  is  an  elevation  of  temperature  aftei-  death.  The  pulse  is, 
as  a  rule,  but  little  affected.  It  may  be  retarded  dining  the  paroxysm  oi'  it 
mav  be  increased  ten  to  twelve  l>eats.  Rapid  inci'case  to  170  to  ISO  usually 
precedes  a  fatal  termination.  List(»ii  declares  that  the  ncsscU  may  be  so  nuich 
cxjntracted  as  to  ])revent  the  escape  of"  a  <li'o|)  of  blood  in  anipiitatioii  of  a  mem- 
ber. The  skin  is  usuallv  covered  with  >w('al,:i  |)oint  often  of  diagnostic  \aliie. 
The  bowels  are  constipated.  There  is  (»ften  suppression,  and  more  fi-e(|iieiit  ly 
retention,  of  urine. 

Diagnosis. — The  diagnosis  largely  rests  upon  the  early  a|)pearance  of 
trismus.  Lockjaw  from  sore  thr<»at,  nnimps,  synovitis,  rheumatism  at  the 
tem|)oro-maxillarv  articulation,  shoidd  be  easily  «listinguished  l)y  the  most 
superficini  examination.       fhe  feel  of  the  rigid  nnisseters  inside  the  mouth  and 


4(i,S  TETANUS. 

the  associate  stiiFiiess  at  the  back  of  the  neck  speedily  dissipate  doubts.  Hys- 
tei-ia  and  hystero-epilepsy  may  show  the  typical  opisthotonos  of  tetanus,  but 
hvsteria  is,  as  a  rule,  unattended  with  trismus,  and  when  trismus  is  simulated 
by  the  fixation  of  the  jaws,  hysteria  is  recognized  by  the  fact  that  the  intervals 
of  attack  are  irregular  and  always  entirely  free  from  spasm  or  pain. 

The  regular  invasion  of  tetanus  from  above  downward,  first  of  the  muscles 
of  the  face  and  neck,  later  of  the  trunk,  distinguishes  the  disease  from  the 
spasmodic  contractions  of  spastic  myelitis.  Cerebro-spinal  and  basilar  menin- 
gitis, which  have  in  common  with  tetanus  stiffness  of  the  neck  and  opisthotonos, 
almost  never  show  trismus.  They  have  also  a  diiferent  origin  and  history, 
are  epidemic  or  tuberculous,  with  associated  symptoms,  such  as  vomiting, 
headache,  hyperfesthesia,  herpes,  etc.,  not  seen  in  tetanus. 

Tetany  is  distinguished  by  its  typical  spasms  of  days'  and  sometimes  weeks' 
diu'ation,  and  absolute  intermissions ;  by  the  peculiar  contraction  or  position 
of  the  hand,  Avhich  may  be  called  out  by  long  pressure  upon  the  nerves  or 
arteries  of  the  arm,  the  so-called  Trousseau  phenomenon ;  by  the  frequent 
laryngo-spasm ;  and  by  the  increased  mechanical  and  galvanic  excitability  of 
the  motor  nerves. 

Hydrophobia,  which  has  in  comuion  with  tetanus  spasm  of  the  muscles  of 
deglutition,  is  distinguished  l)v  the  much  shorter  period  of  incubation,  by 
the  trismus  and  o])isthotonos  of  tetanus,  and  by  the  psychical  exaltation  and 
anxiety  of  hydrophobia. 

By  far  the  most  important  question  in  differential  diagnosis  concerns  the 
recognition  of  poisoning  by  strychnine.  The  poisonous  effects  of  this  alkaloid 
are  most  closelv  simulated  bv  the  effects  of  the  toxines  of  tetanus.  The  diag:- 
nosis  rests  upon  the  following  jjoints  :  The  history  of  origin  where  it  may  be 
ascertained,  the  existence  of  a  wound,  the  period  of  incubation.  Signs  of 
strychnine-poisoning  supervene  at  once.  Tetanus  begins  with  trismus,  and 
gradually  descends,  sparing  as  a  rule,  except  in  children,  the  arms  and  hands. 
Strychnine  often  shows  its  first  signs  in  irritation  of  the  stomach,  and  in  the 
affection  of  the  muscles  seizes  by  preference  upon  the  extremities.  In  tetanus 
there  is  persistent  rigidity;  in  strychnine-poisoning  there  are  intervals  of  ab- 
solute relaxation.  Thus,  in  the  interval  between  the  paroxysms  the  mouth 
remains  closed  in  tetanus,  but  may  be  freely  opened  in  strychnine-poisoning. 
The  reflex  spasms  of  tetanus  occur  later  in  the  course  of  the  disease,  and 
increase  in  intensity,  while  those  of  strychnine  occur  at  once,  intense  from 
the  start.  Strychnine-poisoning  is  quickly  terminated  by  dealh  or  recovery  ; 
tetamis  is  [)rotracted  to  days  and  weeks.  Golding-Bird  reported  the  case  of 
a  boy  affected  with  tetanus  with  spasms  for  fifty-one  days,  with  subsequent 
]iersistent  rigidity  and  death  on  the  one  hundred  and  seventh  day. 

Eiselberg  establishes  as  a  difference  between  tetanus  and  other  wound  infec- 
tions the  fact  that  in  tetanus  local  Avouud  reactions  are  entirely  absent.  So- 
called  cases  of  rheumatic  tetanus  are  therefore  really  of  traumatic  origin. 

The  prognosis  is  exceedingly  grave.  Death  may  occur  in  any  attack  of 
convulsions.     The  heart  has,  actually  under  observation,  suddenly  ceased  to 


PROPHYLAXIS.— TRF.A  TMKXT.  4»i!> 

boat.  Death  occurs,  as  a  rule,  belore  tlic  ciul  of  the  first  week,  so  that,  as 
Hippocrates  said,  '' jiatieuts  die  withiu  lour  days,  or,  if  they  pass  these,  they 
recover."  In  excei>tioual  eases,  however,  the  lata!  tenniuatiou  may  not  occur 
for  tliree  weeks.  The  disease  rarely  lasts  longer  in  children  than  two  or  three 
days.  The  prognosis  is  so  grave  in  the  newly-horn  that  Bauer  ileclares  that 
the  occasional  cases  of  recovery  have  been  looked  upon  as  probable  errors  in 
diagnosis. 

The  prognosis  may  be  determined  in  some  degree  by  the  length  of  the 
period  of  incubation — that  is,  the  interval  between  the  injury  and  the  a])pear- 
ance  of  the  trismus  ;  tor  an  interval  of  less  than  ten  days  gives  a  prognosis 
(tf  96.6  per  cent.,  while  the  general  })rognosis,  inclusive  of  the  cases  of  long 
and  short  interval,  ranges  from  84  to  87.5  per  cent.  The  ])ix)gnosis  stands  in 
direct  relation  to  the  frequency  of  the  paroxysms  and  th(>  rapidity  of  increase 
of  rigidity.  Death  may  take  place  in  cases  of  rapid  recurrence  and  short 
intervals  in  the  short  space  of  two  to  ten  hours.  According  to  Rose,  03 
per  cent,  of  cases  die  within  the  first  five,  and  88  per  cent,  within  the  first 
ten,  days.  The  relief  of  the  later  periods  is  probably  to  be  exj)lained  by  at 
least  partial  elimination  of  the  toxines.  Rigidity  may  persist  for  some  time, 
even  for  months,  after  recovery.  The  ability  to  sleep  is  always  a  lavorable 
sign. 

Prophylaxis. — In  ])revention  of  tetanus  it  is  to  be  emphasized  that  the 
minutest  wounds  soiled  with  earth,  dust,  or  foreign  bodies,  as  splinters,  are  to 
Ije  scrupulously  cleaned  and  disinfected.  The  minutest  fragments  of  splinters 
must  be  removed  immediately.  With  regard  to  the  fact  that  the  secretions  of 
tiie  wounds  of  patients  contain  bacilli,  and  that  the  poison  has  such  great 
resistance  to  desiccation,  it  is  further  strictly  enjoined  that  all  materials  in 
contact  with  the  wound,  dressing,  bandages,  etc.,  are  to  be  destroyed  by  fire — 
that  separate  intruments  are  to  be  used  for  such  patients,  and  the  })atients  them- 
selves are  to  be  isolated  from  otlier  surgical  cases. 

In  prophylaxis  of  the  newborn  it  must  be  observed  that  the  wound  at  the 
navel  is  attended  with  the  utmost  care.  The  asej^tic  treatment  already  recom- 
mended by  various  authors  meets  thus  with  scientific  justification  ;  fi)r  all  the 
investigations  concerning  the  origin  of  th<!  tetanus  bacillus  demonstrate  that 
it  has  an  unusually  wide  ectogenous  dissemination,  rnclcan  hands,  the  use 
of  bandages  not  sufficiently  aseptic,  and  the  raising  of  dust  in  the  cleaning  of 
the  puerperal  room,  suffice  in  the  observations  of  Beumcr  to  convey  the  infect- 
ing agent. 

Treatment. — As  in  hydrophobia  or  otiier  di.sease  characterized  by  exces- 
sive hypenesthesia  of  nerve-centres,  the  patient  should  be  kci)t  perfectly  (piiet. 
He  should  be  ])Ut  in  a  dark  room  and  isolated  from  curiosity  and  officious  or 
meddlesome  ministration.  The  most  absolute  silence  shoukl  be  enjoined  on 
the  part  of  the  patient  as  well  as  the  atteudants.  On  account  of  the  locked 
jaw  the  food  should  be  fluid,  but  should  !»<•  as  luitritious  as  possible.  Milk, 
soft-boiled  egg  diluted  with  hot  water,  imtrieiit  >oii|»s,  stimulants,  as  wine, 
whiskey,  or  brandy,  should  be  regularly  administered.    Where  the  act  ofdeglu- 


4  TO  TF/rANUS. 

tition  oxciti's  spasm  tlie  patient  may  be  aiia^stlietizcd,  and,  according  to  the  sug- 
gestion of"  Rose,  fed  tlirougli  a  tube,  wliieh  may  be,  as  in  the  ease  of  insane  or 
refractory  patients,  inserted  through  the  nose.  Foreign  bodies  should  certainly 
be  inimediateh'  extracted  and  irritated  nerve-trunks  excised.  Angry  wounds, 
*' festering  sores,"  may  be  treated  with  the  powerful  antiuiycotics,  as  carbolic 
acid,  corrosive  sublimate,  or  with  the  actual  cautery.  More  extensive  exsec- 
tion,  and  especially  amputations,  are  surgical  barbarities  of  the  past.  Spas- 
modic contractions  are  best  relieved  by  the  administration  of  anodynes.  Opium, 
on  account  of  its  associate  discomfort  and  distress,  is  better  substituted  in  our 
day  by  chloral.  A  large  dose,  1  drachm  at  first,  may  be  followed  by  smaller 
doses,  15  to  30  grains  every  houi-  or  two,  or  as  often  as  necessary  to  subdue 
spasm.  Calabar  bean  and  c-nrare  have  been  administered  with  success  in  indi- 
vidual cases,  sometimes  of  ([uestionable  diagnosis,  but  these  remedies  have 
failed,  as  a  rule,  to  secure  other  than   temporary  relief. 

Baccelli  recommended  the  injection  of  1  eg.  of  carbolic  acid  every  hour  or 
two  until  the  spasms  entirely  ceased.  Caliari  reported  the  case  of  a  child 
three  years  of  age  which  cut  itself  in  the  left  thumb  with  a  kitchen  knife. 
The  father  stopped  the  blood  with  cobweb.  Tetanus  set  in  in  twentv-seven 
days,  and  was  treated  by  the  method  of  Baccelli  :  1  gramme  of  a  1  per  cent. 
solution  of  carbolic  acid  was  injected  subcutaneously  three  or  four  times  a  dav. 
At  the  same  time  there  were  administered  clysters  of  potassium  bromide,  0.75, 
and  chloral  hydrate,  0.25,  with  warm  baths.  Perfect  cure  was  secured  in 
twenty-seven  days.  Proof  that  the  cobweb  carried  the  tetanus  was  established 
by  experiments  on  a  guinea-pig  and  a  rabbit,  in  whose  bodies  was  introduced 
cobweb  taken  from  the  same  ])lace.  The  animals  died  in  three  davs.  The 
rabbit  showed  exquisite  tetanic  sym])toms. 

Tizzoui  and  CattanI,  as  the  result  of  a  large  number  of  disinfection  experi- 
ments with  [)ure  cultures  of  the  tetanus  bacillus,  found  the  most  effective  sul)- 
stanee  to  be  the  nitrate  of  silver,  which  destroys  the  spores  of  the  tetamis 
bacillus  in  a  1  per  cent,  solution  in  one  minute;  in  the  proportion  of  1  :  1000, 
in  five  minutes.  Sublimate  solutions  of  the  same  strength  require  ten  minutes. 
Creolin  in  o  ])ei'  cent,  solution  destroys  tetanigenic  spores  in  five  hours;  iodine 
in  six  hours;  <'arbolic  acid,  -5  ])er  cent.,  in  eight  hours;  permanganate  of 
])otassium,  1  per  c<Mit.,  in  ten  hours.  The  injection  of  mytilo-toxine,  the 
active  principle  of  the  |)oisonous  mushroom  (toadstool),  as  a  therapeutic 
measure  proved  valueless. 

The  hope  of  successfid  treatment  lies  in  the  use  of  the  antitoxines,  derived 
from  the  blood-S(>rutii  of  inunune  animals  (dogs)  or  from  the  bodies  of  the 
hacteria  themselves. 

Jk'hring  and  Kitasato  concluded,  first,  that  the  blood  of  rabbits  rendered 
imnnnie  to  tetanus  j)ossesses  antitoxic  properties  ;  second,  these  properties 
exist  also  in  extravascular  blood,  and  are  demonstrable  in  the  serum  of  such 
blood  free  of  cells  ;  third,  these  properties  are  so  permanent  that  they  remain 
effective  in  the  organism  of  other  animals,  so  that  it  is  possible  by  means  of 
the  transfusion   of  blood — i.e.  sci-um — to  secure  thera[)eutic  effects;    fourth, 


TREAT.UI'jyr.  471 

tlic  antitoxic  properties  do  not  exist  in  the  blood  of  animals  \vhi(Oi  enjoy  no 
irnnuniity  to  tetanus,  and  the  tetanus  poison  introduced  into  the  bodies  of  such 
animals  remains  demonstrable  in  the  blood  and  other  Huids  after  the  death  of 
the  animals,  A  normal  rabbit  succumbs  to  the  injection  of  0.05  ccm.  tetanus 
poison,  A  protected  animal  may  be  inoculated  with  10  ccm.  without  injiuy. 
Such  an  animal  has  immunity  not  only  against  the  tetanus  l)acillus,  but  also 
iiirainst  the  tetamis  poison,  and  may  receive  without  damage  twenty  times  as 
much  poison  as  would  be  absolutely  fatal  to  normal  rabbits,  hi  ancient 
times  the  transfusion  of  blood  was  regarded  as  an  heroic,  but  in  certain  cases 
an  extremely  valuable,  remedy.  The  results  obtained  by  these  experiments 
with  the  serum  of  blood  furnish  new  proof  that  "  the  blood  is  a  very 
]H'culiar  juice," 

Vaillard  was  able  to  contirm  the  conclusions  of  Behring  and  Kitasato  con- 
cerning immunity  from  tetamis.  The  serum  of  rabbits  rendered  refractory  to 
tetanus  possesses  protective  properties;  but  immunity  secured  in  this  Avay  is 
n(»t  permanent.  It  begins  to  diminish  in  the  mouse  in  fourteen  days,  and  dis- 
appears in  the  guinea-pig  between  the  eleventh  and  fourteenth  days.  Neither 
aqueous  humor  nor  the  spleen  of  refractory  animals  extracted  during  life 
possesses  the  properties  of  .serum.  The  fowl  is  insensitive  to  large  do.ses  of 
tetanic  poison,  yet  the  serum  of  the  fowl  has  no  antitoxic  effect.  The  sennn 
of  a  rabbit  which  had  resisted  every  effort  at  inoculation  had  not  the  slightest 
antitoxic  effect.  This  effect  occurs  only  in  animals  to  whom  immunity  has 
been  given  artificially.  It  is  conferred  by  the  injection  of  a  large  (jnantity 
of  a  filtrated  culture.  Thus  it  may  be  im])arted  to  the  serum  of  the  fowl  by 
the  intraperitoneal  injection  of  lo  to  20  ccm.  of  filtered  culture. 

Schwarz  i-cports  a  case  of  cure  of  tetamis  traumaticus  with  the  antitoxine 
])repared  by  Tiz/oni  and  Cattani,  This  case,  after  failure  of  other  remedies, 
yielded  to  the  inj(»ction  of  antitoxine  20  ctg.  The  |)atient  had  been  previously 
])ut  under  chloroform,  A  j)art  of  the  wound  had  been  excised  and  the  wound 
disinfected  with  a  3  })er  cent,  scdntion  of  sublimate  and  a  4  per  cent,  solu- 
tion of  nitrate  of  silver.  The  antitoxine  was  injected  during  amesthesia,  and 
was  repeated  on  the  following  day.  The  patient  left  tlie  hospital  perfectly 
cured.  The  author  quotes  from  Gagliardi  a  similar  unpublished  case  in 
which  1  gramme  of  the  agent  sufficed  to  remove  ail  symptoms  of  tetanus 
and  bring  about  a  complete  recovery.  Paschini  recorded  a  third,  ( 'asali  now 
a  seventh,  case  rescued  in  this  way.  The  treatment  consists  in  the  injection 
of  the  tetanus  antitoxine  obtained  fioni  th<'  blood  of  a  dog  i-eiidered  immiuie 
to  the  disease,  25  eg.  being  injected  twice  a  day.  Such  imj)rovcment  occiu-s 
in  the  course  of  a  week  as  to  render  the  further  use  of  the  rcnuMly  unneees- 
sary,  and  the  treatment  is  usually  eoncluded  with  the  hycb-atc  of  chloral. 
Unfortunatclv,  all  th*,-  best  observers  do  not  confirm  these  conclnsious.  Kita- 
sato was  not  able  to  get  inuiuniity  by  tolerance  nor  by  the  use  of  fdtratcs 
attenuated  by  lu-at.  Rabbits  were  rendered  immune  in  40  per  cent,  of  cases 
with  the  trichloride  of  iodine,  but  the  immunity  was  lost  in  the  course  of  (wo 
months.      Immunity  i.>  conferred  upon  mice   by  the  injection  of  the  .serum  of 


472  TETANUS. 

iininmiizcd  rabl)it,s,  but  this  immunity  is  lost  in  forty  or  fifty  clays.  The  fowl 
is  by  nature  immune  to  tetanus,  but  the  blood  of  the  fowl  does  not  confer  im- 
munity upon  other  animals. 

By  the  second  method,  Ehrlich,  Brieger,  and  Wassermann  utilize  the  anti- 
toxines  developed  by  the  bodies  of  bacteria  themselves,  after  the  manner  of 
Koch  with  tuberculin.  These  antitoxines  or  protective  bodies  are  to  be 
obtained  in  the  milk  of  parturient  animals  previously  rendered  immune  in 
])rcgnancy  by  the  inoculation  of  an  attenuated  culture  which  is  gradually 
increased  in  virulence.  The  protective  principle  remains  in  the  whey  after 
coagulation  and  separation  of  the  casein,  so  that  it  may  be  preserved  indef- 
initely. Some  of  the  most  sensitive  of  the  lower  animals,  mice,  goats,  et«., 
liave  already  been  protected  in  this  way,  but  at  the  tiraeof  tlie  present  writing 
no  account  has  been  published  of  any  work  with  man. 


ACTINOMYCOSIS. 

By  JAMES  T.  WIIJTTAKEK. 


Actinomycosis  {axrcz,  axrti^o::,  ray  ;  /xOxr^::,  f  niigns),  Big  jaw,  Swelled  head, 
Bonetiiiuor;  Ger.  Kinn-beule,  Holzzunge,  Knoehenkrebs, — a  peculiar  infec- 
tion of  cattle  communicable  to  man,  caused  by  the  ray  fungus,  actinomyces, 
characterized  by  development  of  the  fungus  in  mass  with  ex'cessive  overgrowth 
of  the  soil  in  which  it  grows,  attended  by  metastases  to  different  organs,  marked 
by  symptoms  of  pysemia  and  marasmus,  and  distinguished  always  by  the  detec- 
tion of  particles  of  the  fungus  itself  in  the  mass,  in  its  metastases,  and  in  its 
discharges. 

Bollinger  (1877)  first  saw  the  fungus  as  the  cause  of  the  disease  known  as 
the  big  jaw  in  cattle.  In  this  affection,  which  the  veterinary  surgeons  had 
considered  hitiierto  a  purely  local  disease,  especially  of  the  jaw,  and  sometimes 
also  of  the  tongue,  throat,  stomach,  etc.,  and  which  they  had  called  big  jaw, 
wooden  tongue,  throat  boil,  bone  cancer,  etc.,  Bollinger  discovered  for  the  first 
time  an  extraordinary  fungus  as  its  cause.  He  took  a  specimen  of  it  to  Harz, 
a  botanist  of  Munich,  who  gave  it  the  very  appropriate  name  it  bears — actino- 
myces, ray  fungus.  Hereupon  Bollinger  designated  the  disease  M'hich  it  \n-o- 
duces  as  actinomycosis. 

Israel  of  Berlin  also  saw  the  parasite  in  man  in  the  year  of  its  discovery 
in  cattle,  and  described  it  as  a  new  mycosis  of  man.  Ponfick  (1879)  estab- 
lished the  identity  of  the  disease  caused  by  it  in  man  with  the  actinomycosis  of 
cattle.  In  tiie  first  observation  in  man  the  disease  ran  its  course  as  a  peculiar 
form  of  chronic  pyfcmia.  Israel  succeeded  in  distinguishing  the  ])arasite  itself 
during  life  in  the  discharges  from  various  abscesses  from  the  skin,  the  hu-gcst 
«if  which,  as  post-mortem  examination  subsequently  showed,  communicated 
with  the  left  lung.  Fragments  of  the  parasite,  varying  in  size  from  a  niillet- 
see<l  to  an  :i])])Ie,  were  discovered,  also  after  death,  in  the  liver,  kidneys, 
spleen,  and  intestine.  Israel  subsequently  encountered  the  same  formations  in 
other  cases  of  local  abscesses,  evi<lently  extending  fr* uii  carious  teeth,  as  well 
as  in  the  root-canals  of  the  teeth  themselves;  whence  lie  inferred  that  the 
mouth  was  the  avemie  of  entrance,  and  that  the  |)arasite  was  cari'ied  by 
as])iration  to  the  lungs,  from  which  ])oint  it  was  disseminated  by  metastases 
to  internal  (»rgans  and  to  the  skin.  Israel  now  recognized  that  a  case  in  the 
]>ractice  of  liangenbeek,  a  liitnl  jucvertebral  ])hlegmon,  had  deju'iuled  on  the 
same  cause.  In  subsequent  observations  the  author  demonstrated  the  origin 
of  the  disease  not  only  from  teeth,  l)ut  also  from  tonsils,  in  whose  crypts  frag- 

•I7;i 


474 


A  (^rrxoMYCOsrs. 


inente  were  foniui.  These  (>l)serv:itioiis  were  speedily  cHjntirmed  by  others,  so 
that  the  disease  imniediately  took  u  recoij:nized  place  in  pathology.  Belfield  of 
Cliieao-Q  first  reeotrnizcd  the  parasite  in  cattle  in  our  own  country  as  the  cause 
(»(■  the  disease  known  as  swelled  head,  technically  as  jaw  sarcoma. 

Actinonivces  constitutes  a  mass  so  large  tis  to  he  visible  to  the  naked  eye. 
It  consists  of"  a  (Conglomeration  of  innumerable  threads  of  mycelia  about  a 
central  mass  of  the  same  structure,  from  which  the  threads  radiate  in  every 
direction  to  construct  the  ray  shape.  The  mycelia  can  be  always  recognized  by 
their  clubbed  extremities  (see  Fig.  29),  and  the  mass,  on   an  average  about 


Kiu.  29. 


W0^ 


^^^ 


9 


•m 


'sMv 


mm 


*^^-: 


.VftinoiuycL's  \\ .  Jakscln. 


one-fortieth  of  an  inch,  is  as  large  at  times  as  one-tenth  of  an  inch  in  diameter. 
Agglomerated  masses  may  be  as  big  as  a  fist.  Frngments  detached  and  dis- 
<'harged  have  a  tallowy  consistence  and  a  distinctly  greasy  feel.  Peripheral 
protrusions  divide  dichotomously,  and  show,  as  stated,  distinctly  clubbed  or 
pear-shaped  extremities,  to  resemble  in  certain  fragments  the  apj^earance  of  a 
hand  or  glove  with  outstretched  fingers.  The  j)eripheral  radiation  from  a 
<'entral  mass  gives,  under  the  microscope,  something  of  the  appearance  of  an 
aster  or  sunflower.  Many  deviations,  however,  may  occur  from  this  classical 
type.  The  size  of  the  individual  mass  m;iy  vary  from  barely  visible  granules 
iij)  to  masses  of  measurable  diameter. 

Besides  the  typical  yellow  color,  particles  may  be  seen  colorless,  trans- 
])arent,  greenish,  oi-  brown.  The  young  granules  are  whitish-gray,  the  very 
youngest  gelatinous,  almost  (lifflu(>nt  ;  the  older  colonies  are  opaque,  and 
the  oldest  yellowish-brown  and  yellowish-green.  The  surface  may  be  gran- 
ulated, mulberry-form.  Harz  and  Johne  tried  in  vain  to  cultivate  it.  Israel 
finally  succeeded  with  coagulated  blood-serum,  but  with  such  different  appear- 
ance from  the  normal  structure  as  to  make  it  impossible  to  decide  upon  the 
exact  botanic  relations  of  the  microphyte.  Bostr<)m  succeeded  best  with 
granules  floating  free  in  pus  or  lying  loose  in  granulaiion-tissue.  Wolff  finally 
inoculated  the  disease  with  pure  cultures  of  actinomyces.  The  mass  is  colored 
with  difficulty,  though  the  mycelia  at  the  j)eriphery  absorb  the  aniline  dyes, 
especially  gentian  violet,  and  retain  them.     Fine  pictures  are  made  with  dou- 


PATHOLOdY.  475 

l)le  colorations,  as  by  the  method  of  Gram,  and  subsequent  stain  with  eosine. 
(See  Fig.  30.) 

Fio.  30. 


Actinomyces:   Double  Stain  l»y  Gram's  Method. 

Tiie  patholog-y  of  the  affection  differs  in  man  from  tiuit  of  the  lower  ani- 
mals in  that  the  process  in  the  animal  is  a  local  swelling,  a  so-called  granula- 
tion tumor,  while  in  man  the  tendency  is  toward  a  suppurative  process  with 
metastatic  dissemination,  so  that  the  disease  in  man  runs  its  course  with  the 
formation  of  multi])k'  abscesses  and  showing  the  characteristics  of  chronic 
j)y{emia.  The  difference  is  explained  by  the  belief  that  the  process  is  not 
])ure  in  man,  but  is  attended  with  mixed  infections,  especially  with  the 
penetration  of  the  [)yogenic  micro-organisms.  Of  the  9  cases  reported  by 
Baracz,  in  onlv  1  was  there  a  pure  actinomycosis  :  in  all  the  others  there 
was  subsequent   infection  with   the  micro-organisms  of  pus. 

The  suppurative  process  in  man  is  attended  also  with  a  distinct  tendency 
to  extensive  fatty  degeneration.  Prej)arations  of  the  granulation-tissue  show 
great  accumulations  of  fatty  degenerated  cells. 

The  most  tVequent  avenue  of  entrance  in  man  is,  as  stated,  the  cavity  of 
the  mouth,  and  especially  tlic  teeth  whose  surface  is  broken  with  caries;  next 
the  bones  of  tlie  jaw  ;  less  fre(|uently  solutions  of  conti?uiity  in  the  pharynx 
and  tonsils.  More  than  half  of"  all  the  eases  hitherto  observed  in  man  have 
arisen  in  this  wa\-.  The  origin  of  the  disease  is  ascribed  to  the  ingestion  of 
vegetable  food,  especially  certain  cereals.  The  fact  that  the  disease  occurs  so 
frcfjuentlv  in  cattle  excites  si\spicion  in  this  direction.  I*ricl<lv  fodder  breaks 
the  surface  for  the  recej)tion  of  the  fungus.  Johne  found  granules  upon  cer- 
tain grains,  especially  of  barley,  whose  free  en<l  was  covered  with  a  mycophytic 
growth  which  presented  much  similarity  to  a  mass  of  actinomyces.  Jensen,  a 
veterinary  siwgcon  of  Denmark,  observed  an  endemic  of  actinomycosis  in  cat- 
tle after  feeding  them  with  barley  which  had  lain  for  some  time  upon  moist- 
ened soil,      Kndemics  after  HockIs  and   immdations  show  the  eff-ect  ol'  moistuie 


47(3  A  CTIXOMYCOSIS. 

in  developing  the  fungns.  Piana  discovered  fibres  (j1'  various  cereals  in  the 
actinomycotic  growths  removed  from  the  tongue  of  a  cow  aifected  with  the 
disease.  Tliese  fibres  were  surrounded  with  characteristic  vegetations  of  acti- 
noniyces.  Brazola  saw  masses  of  fungus  on  fragments  of  barley  in  the  gums 
of  individuals  aifected.  Baracz  reported  9  cases  of  human  actinomycosis — 
2  acute  and  7  chronic.  (3ne  individual  was  said  to  have  chewed  the  ears  of 
barlev;  one  patient  lived  in  the  vicinity  (»f  stables  for  horses;  a  third  drank 
daily  of  lukewarm  milk  in  the  stable.  In  others  no  possible  contact  could 
be  discovered  either  with  cattle  or  grain'.  In  these  cases  the  disease  developed 
itself  in  the  region  of  the  lower  jaw — in  one  at  the  point  of  the  tongue,  and 
in  one  on  the  neck  in  the  region  of  the  larynx.  The  avenue  of  entrance  in 
man  bespeaks  the  same  origin — that  is,  from  some  vegetable  source. 

Symptomatolog-y. — The  disease  demonstrates  itself  as  a  torpid  and  but 
slightly  painful  growth,  which  finally  perforates  the  skin  with  sinuous  tracts 
and  various  fistulous  orifices.  Some,  if  not  most,  of  the  great  tumors  or 
masses  in  the  region  of  the  lower  jaw  formerly  diagnosticated  as  cases  of 
anffina  Ludovici,  which  constituted  in  ancient  times  a  much-dreaded  malady, 
were  certainly  cases  of  actinomycosis  of  the  lower  jaw.  Besides  the  pene- 
tration of  the  teeth,  the  parasite  finds  entrance  into  the  body  of  man  by  way 
of  the  bronchi,  and  also  by  way  of  the  intestinal  canal.  Thus,  there  is  an 
actinomycosis  of  the  jaw,  of  the  lungs,  and  of  the  intestine.  The  disease  dis- 
tinguishes itself  by  its  gradual  encroachment  upon  tissues  hard  and  soft  in  its 
vicinity.  It  expands  bone,  enlarges  the  natural  outlines  of  the  neck,  convert- 
ing the  skin  into  a  mass  of  cicatricial  tissue,  finds  its  way  at  times  into  the 
anterior  mediastinum,  and  finally,  after  a  laj)se  of  nu)nths  or  years,  causes  the 
death  of  the  individual  by  a  slow  process  of  suppuration  or  by  a  quicker  suf- 
focation or  occlusion  of  larger  vessels. 

It  may  be  distinguished  upon  the  surface  by  the  mass  of  cicatricial  tissue ; 
bv  the  formation  of  abscesses  with  subsequent  discharge  without  offensive 
odor,  often  through  fistul?e  of  sinuous  tracts;  and  absolutely  by  its  yellowish 
granules  of  the  size  of  grains  of  sand,  visible  to  the  naked  eye,  greasy  to  the 
feel,  which,  when  placed  under  the  microscope,  reveal  the  distinctive  charac- 
teristics of  the  growth. 

Entering  the  bronchial  tubes,  it  produces  a  peculiar  form  of  bronchitis, 
most  closely  allied  to  putrid  bronchitis,  save  that  the  offensive  discharge  w'hich 
is  expectorated  separates  into  two  instead  of  three  layers — an  upper  super- 
natant, and  a  lower  turbid  fluid  containing  the  actinomyces.  In  the  lungs 
l>roper  the  disease  gives  rise  to  the  symptoms  of  tuberculosis,  and  has  been  not 
infrequently  mistaken  for  this  disease.  The  gradual  decline  of  health  and 
strengtli,  the  progressive  emaciation,  cough,  suppuration,  night-sweats,  make 
it  closely  resemble  tuberculosis.  In  cases  of  more  ra})id  progress  the  disease 
may  simulate  jjneumonia  with  its  glutinous  muco-purulent  or  rusty  sputa,  dul- 
ness  to  percussion,  and  bronchial  respiration.  Metastatic  processes  from  these 
centres  disseminate  the  parasite  to  distant  organs,  most  frequently  to  the  sub- 
cutaneous and  intermuscular  connective  tissue,  and  also  to  the  various  viscera — 


DIA  GNOSIS.—  TRIL 1 TMKNT.  477 

liver,  kidnevs,  intestine,  heart,  and  hrain.  The  irrnption  into  thi'  vari»)U.s 
serons  eavities,  })leni'a,  perieaixlinni,  peritoneum,  meninges,  qniekiy  ean.ses 
fatal  inflammation.  Cases  whieli  escape  these  calamities  survive  to  succuml) 
to  amyloid  degeneration  with  anasarca  and  more  protracted  marasmus,  the  dis- 
ease lasting,  mayhap,  two  or  three  years. 

In  the  intestine  the  mucous  membrane  shows  whitish  patches  covered  with 
yellowish  granules,  firndy  adherent  to  the  membrane  upon  which  it  rests. 
Various  swellings  appear,  therefore,  in  its  course,  some  of  which  suppurate 
and  discharge  their  contents  at  times  into  the  peritoneal  sac,  or,  after  aggluti- 
nation to  the  parietal  peritoneum,  with  subse((uent  discharge  externally. 
Metastases,  which  are  rare  on  account  of  the  size  of  the  growth,  carry  the 
disease  to  the  liver,  where  the  growths  may  attain  considerable  magnitude. 
So  metastasis  through  the  jugulars  has  develo})ed  masses  in  the  lungs  and 
heart. 

Diagnosis. — The  disease  may  be  distinguished  from  ordinary  affections  of  the 
jaw  by  its  long  duration,  its  tedious  suppuration,  its  recurrence  after  incom]dete 
exsection,  its  periods  of  quiescence,  and  its  defiance  of  all  ordinary  treatment. 
In  the  lungs  it  affects  the  posterior  and  lateral  ])ortions,  rarely  the  apices,  and 
jn  the  intestine  it  reveals  nodular  masses  which  may,  at  times,  be  felt  beneath 
the  surface.  Neither  the  enlargement,  suppuration,  nor  general  symptoms,  how- 
ever, absolutely  declare  the  disease,  whose  nature  is  only  definitely  established  by 
the  recognition  of  fragments  of  the  parasite  with  the  eye  and  its  characteristic 
elements  under  the  microscope.  Certain  apparently  inscrutable  cases  of  cryp- 
to-genetic  infection  have  been  unveiled  as  actinomycosis.  One  of  the  most 
remarkable  of  these  cases  was  that  mentioned  by  Bollinger  of  an  apparently 
primary  actinomycosis  of  the  brain.  Fischer  remarks  that  the  presence  of 
vegetable  fibres  in  any  purulent  discharges  should  excite  susjiicion  of  the  eti- 
ology of  the  disease. 

Prophylaxis  includes  the  supei'vision  of  the  food  of  animals;  the  avoid- 
ance of  tlK)rny  or  })rickly  twigs  and  plants,  as  well  as  of  moist  or  wet  food  ; 
the  absolute  destruction,  as  by  fire,  of  all  actinomyces  in  diseased  organs  of 
slaughtered  animals  ;  and  enjoins  above  all  things  the  most  scruj)ulous  care 
of  the  tcetli  and  mouth. 

Treatment. — The  treatment  is  almost  entirely  surgical.  It  consists  in  the 
complete  ex.section  and  enucleation  of  the  (Mitiije  mass  with  the  knife  or  its 
thorougli  eradication  and  destruction  with  caustic.  The  parasite  seems  to  be 
singularly  suscejitible  to  the  nitrate  (»!'  silvci-.  Kitttnitz  cui-ed  four  cases  witii 
the  solid  stick,  aj)j)li(Hl  and  inserted  freely  in  every  dii-ection.  Favorable 
results — /.  ('.  death  of  the  growth  and  rescue  of  the  patient — have  been  secured 
in  individual  eases  by  injections  of  the  ferric  sidphate,  tincture  of  iodine,  car- 
bolic acid,  or  coi-rosive  sublimate,  as  also  by  eniitei'izatlon  with  zinc  chloride 
and  the  internal  u.^e  of  potassium  iodide.  Jiillroth  succeeded  in  curing  a  case 
with  tuberculin. 


ANTHRAX. 

By   JAMPIS  T.  WHITTAKER. 


Anthrax  {dvOfw.^,  coal),  Carbiinclf,  Malignant  })u,stule,  Splenic  fever, 
Bloody  murrain  ;  German.  Milzbrand  ;  French,  Charbon,  Pustule  maligne ; 
Russian,  Jaswa  (boil-plague), — an  ex(jnisitely  acute,  often  fatal  infection,  caused 
by  the  bacillus  anthracis,  and  chara(!terized  by  the  formation  of  a  boil  with 
a  black  centre  (anthrax),  extensive  circumjacent  intiltiation,  and  subsequent 
sepsis;  in  internal  form  by  rapid  toxicsemia  and  the  development  of  metas- 
tatic carbuncles  in  the  skin.  Anthrax  existed  in  the  most  remote  antiquity. 
It  is  recognized  that  most  of  the  fatal  plagues  which  formerly  affected  animals, 
and  not  infrequently  men,  correspond  to  the  symptomatology  of  anthrax.  The 
plague  of  murrain,  with  boils  and  blains  on  man  and  beast,  mentioned  in  Gen- 
esis, is  believed  to  be  of  this  nature  (Blanc). 

The  disease  is  universal,  but  is  manifest  in  intensity  more  especially  under 
the  primitive  agriculture  of  the  lower  civilizations  as  connected  with  the  nature 
of  the  soil  and  the  food.  In  its  internal  or  intestinal  form  it  is  exquisitely 
infectious  and  fatal.  In  San  Domingo,  in  1770,  15,000  })ersons  perished  in 
six  weeks  froui  eating  the  bodies  of  animals  dead  of  the  disease.  Law  declares 
that  in  the  worst  anthrax  years  in  some  of  the  Siberian  steppes  as  much  as  one- 
fourth  of  the  wdiole  population  was  attacked  \vith  anthrax.  Kircher  ascribes 
the  death  of  60,000  peoj^le  in  the  vicinity  of  Naples  in  1617  to  the  same  cause. 

The  bacillus  anthracis  is  famous  as  the  first  micro-organism  discovered  as 
the  actual  cause  of  an  infectious  disease.  It  is  the  longest  known  and  best 
studied  of  all  the  micro-organisms.  The  real  acquisitions  of  modern  bac- 
teriology, with  attenuations,  involutions,  toxines,  antitoxines,  have  been  made 
n)ostly  Avith  the  anthrax  bacillus.  This  bacillus  was  first  recognized  by  Pollen- 
der  (1855)  and  Brauell  (1857),  but  was  regarded  as  a  lifeless  crystal  by  the  op- 
ponents of  the  germ  theory  because  it  showed  no  motion.  Davaine  demon- 
strated its  infectiousness,  and  Koch  the  growth  of  the  rods  in  long  threads, 
the  formation  of  endogenous  spores,  the  liberation  of  these  spores,  and  their 
development  into  new  rods.  When  it  was  opposed  to  all  these  disclosures  that 
tiie  symj>toms  of  the  disease  were  produced  by  a  chemical  substance,  anthracin, 
independent  of  any  micro-organism,  it  was  immediately  demonstrated  by  Koch 
that  the  disease  arises  only  from  such  substances  as  are  evolved  from  the  bacil- 
lus anthracis  and  its  spores. 

The  milzbrand  bacillus  is  a  motionless  rod  of  elongated,  jointed  cells 
.005-.0125  mm,  in  length — /.  e.  two  to  ten  times  as  long  as  a  red  blood- 
corpnscle — .001    to  .0015   mm.   broad.     (See  Fig.    31.)     Under   pro})er  con- 

478 


ANTHRAX.  479 

(litiont!  it  f■orms^  in  the  culture-soil,  but  nevoi-  inside  of  the  body  or  tissues  of 
the  living  animal,  endogenous  spores,  in  which  process  it  requires  absolutely 
an  abundant  admission  of  free  oxygen   and   a   tietinite  temperature  ranging 

Fig.  3J. 

/    f,  -* 

Bacillus  Anthracis. 

between  18''  C.  and  34°  C,  best  at  30°  V.  It  is  easily  colored  by  any  of 
the  aniline  dyes  and  readily  yields  its  color.  The  sjiores  are  colored  with 
grciit  difficulty,  so  that  double  coloration  is  easy.  Anthrax  bacilli,  like  all 
endogenous  bacilli,  are  not  very  tenacious  of  life,  but  the  spores  are  extremely 
resistant  and  constitute  the  permanent  forms.  The  bacilli  ])erish  under  desic- 
cation in  several  days ;  the  spores  resist  it  for  many  years.  They  can  Avith- 
stand  a  5  ])er  cent,  solution  of  ciarbolic  acid  for  thirty-seven  days,  while  the 
bacilli  are  destroyed  by  a  1  per  cent,  solution  in  ten  seconds.  I)ecomj)osition 
or  the  action  of  the  gastric  juice  quickly  destroys  the  bacilli,  but  fails  to  attack 
the  spores.  The  ingestion  of  meat  free  of  spores  produces  no  infection  ;  the 
ingestion  of  meat  with  spores  infects  infallibly.  This  destruction  of  the  bacilli 
is  probably  jteptic — /.  c.  metabolic.  ]t  is  certainly  not  due,  as  formerly 
believed,  to  the  action  of  the  hydrochloric  acid  of  the  gastric  juice,  for 
Dyrmont  demonstrated  that  milzbrand  bacilli  maintain  their  virulence  forty- 
eight  hours  in  a  ]  j)er  cent,  solution  of  hydrochloric  acid  ;  wh(!rcas  the  gas- 
tric juice  of  man  contains  at  most  but  0.2  per  cent  of  hydrochloric  acid. 
Freezing  affects  neither  the  bacilli  nor  the  spores. 

Anthrax  infects  chiefly  herbivora,  next  onniivora,  among  which  is  man, 
and  least  of  all  carnivora.  The  disease  is  therefore  not  quite  so  dangerous  in 
man  as  in  some  other  animals.  The  ba<;illus  anthracis  is  a  sa])roi)hytc.  It 
goes  through  with  all  its  phases  of  development  outside,  and  makes  only  acci- 
dental incursion  into  the  body  of  man.  Martin  succeeded  in  extracting  from 
cultures  certain  chemical  products:  first,  ))roto-  and  dcutero-albumose ;  second, 
an  alkaloid  ;  third,  small  (|nantities  of  leucin  and  tyrosin.  Mice  injected 
with  the  proto-  and  <lcutero-albumose  were  affected  with  cedema  at  the  j)lacc 
of  injccticm,  and  with  a  sufficient  quantity  (0.3  gr.  for  a  mouse  weighing  22 
gr.)  they  were  killed.  Similar  symptoms  were  ])rodnced  with  the  alkaloid, 
0.1  gr.  being  fatal  to  a  mouse  weighing  lo  gr.  Ilankin  also  found  an  albu- 
mose  which  he  injeet<'(l  as  a  |>i(tpliylactic  against  the  disease.  Anthrax  is 
peculiarly  malignant  in  small  animals.  It  is  so  surely  and  (|uickly  fatal  to 
mice,  guin(!a-]»igs,  and  rabbits  as  to  make  ol"  tlicir  bodies  flic  i)cst  physio- 
logical tests  in  c^ise  of  tloubt   as  to  the  nature  (»f  a   micro-organism. 

Anthrax  is  usually  citnvcycd  to  man  by  contact  with  a  diseascHl  animal  oi' 
bv  the  ingestion  ol    it-  Mcsli  as  food.      Indisidnals  most  chf-cly  coinicctcd  with 


480  ANTHRAX. 

cattle  are  cliieHy  affected — butchers,  stable-boys,  shepherds,  veterinary  physi- 
cians, etc.  On  account  of  the  great  tenacity  of  the  spores  people  who  come  in 
contact  at  anv  time  with  the  skins,  hairs,  bristles,  cloths,  horns,  or  hoofs — as 
tanners,  brnshraakers,  upholsterers  (horse-hair),  wool-sorters,  rag-sorters,  glue- 
makers,  etc. — may  be  affected  through  open  wounds  in  the  skin  or  through 
inhalation  of  dusts. 

Since  Bollinger  demonstrated  the  bacillus  in  the  stomach  of  carnivorous 
flies  and  with  Raimbert  and  Davaine  produced  the  disease  by  inoculation 
-with  the  stomach,  legs,  and  feelers  of  these  insects,  it  must  be  admitted  that 
malio-nant  pustule  may  be  conveyed  by  insects.  It  had  long  been  remarked 
that  malignant  pustule  occurs  more  especially  on  the  exposed  parts  of  the  body, 
face,  and  hands.  Bell  of  Brooklyn  found  56  of  60  cases  on  the  face,  2  on  the 
hands,  1  on  the  Avrist,  and  1  on  the  forearm.  It  was  evident  that  the  bite  of 
!x  fly  or  mosquito  had  often  originated  the  disease.  Extensive  epidemics  have 
been  caused,  as  stated,  by  the  ingestion  of  raw  or  insufficiently  cooked  flesh. 
Animals  rarely  contract  the  disease  from  each  other;  they  get  it  from  the  soil. 
It  has  often  been  observed  that  certain  regions  are  centres  of  infection  wherein 
the  disease  shows  itself  year  after  year.  The  superficial  burial  of  carcasses 
leads  to  infection  of  the  soil,  which,  once  produced,  is  seldom  eradicated.  The 
disease  is  spread  chiefly  in  the  warm  months  of  summer,  when  the  soil  is  softer, 
bv  animals  grazing  upon  its  surface,  and  is  transported  by  streams  of  water, 
which  convey  the  infected  soil  to  a  distance.  Floods  may  disseminate  the  dis- 
ease to  places  previously  free.  Stable  utensils,  fodder,  hay  from  anthrax  fields, 
litter,  harness,  sui'gical  instruments,  have  been  known  to  convey  the  disease. 
The  foetus  is  not  infected  as  a  rule.  The  placenta  when  sound  acts  as  a 
filter.  Exceptional  cases  have  been  accounted  for  by  lesion  of  the  placenta. 
Immunity  is  not  secured  by  a  single  attack. 

Morbid  Anatomy. — There  is  usually  marked  cadaveric  rigidity,  some- 
times, but  seldom,  cyanosis.  Decomposition  occurs  early.  The  blood,  which 
is  black,  thick,  and  uncoagulable,  shows,  especially  in  the  lungs,  liver,  kid- 
neys, and  spleen,  abundant  bacilli  or  spores.  The  skin,  when  the  disease  has 
located  itself  in  its  structure,  shows  the  signs  of  an  extensive  destruction  of 
tissue,  with  intense  oedematous  infiltration,  sometimes  with  gangrene.  The 
outlying  lymphatics  are  swollen  and  luTemorrhagip.  In  the  internal  mycosis 
the  surface  may  show  metastatic  carbuncles  and  petechi;^.  The  spleen  shows 
constant  lesions  (hence  the  terms  splenic  fever,  milzbrand).  It  is  increased  to 
double  or  quadruple  its  natural  size,  and  is  distended  with  blood,  often  to 
rupture.  Sometimes  it  shows  gangrene.  When  the  affection  originates  in  tiie 
intestine  this  structure  shows  hsemorrhagic  infiltration  and  gangrene.  The 
retro-peritoneal  lymph-glands  and  mesenteric  glands  are  hyperaemic  and  haem- 
orrhagic.  Hiemorrhages  into  the  serous  sacs,  degeneration  of  the  heart-mus- 
cle, of  the  liver,  and  of  the  kidneys,  belong  to  .this  disease,  as  to  all  the  ex- 
quisitely acute  and  grave  infections. 

Syin])tomatolog-y. — The  disease  presents  itself  in  two  distinct  forms — one 
as  it  originates  externally,  the  other  internally.     The  external  disease  is  the 


SYMPTOM  A  TOL  O  G  Y.  48 1 

antlirax,  malignant  pustule,  or  oliarbon,  with  its  lesions  in  the  skin  and  sub- 
jacent tissues:  the  internal  is  the  intestinal  or  thoracic  mycosis,  which  is 
recognized  by  the  general  signs  of  toxicsemia,  the  nature  of  which  may  be,  if 
unsuspected,  overlooked.  The  external  disease  is  confined  to  individuals ;  the 
internal  may  assume,  as  stated,  endemic  and  epidemic  proportions. 

The  period  of  incubation  varies  from  one  to  several  da)s.  Symptoms  may 
show  themselves  in  a  few  hours  after  inoculation  ;  they  may  be  delayed  as  late 
as  four  days.  A  slight  itching,  prickling,  or  burning  sensation  is  first  per- 
ceived on  the  face  or  neck  at  the  site  of  inoculation.  Sometimes  the  patient 
feels  as  if  he  had  just  been  stung  by  an  insect.  Very  soon  there  appears  a  pap- 
ule with  a  central  vesicle,  the  rupture  of  which  discharges  bloody  contents,  to  be 
converted  into  a  dark  red-brown  or  black  crust,  the  anthrax.  Smaller  vesicles 
may  appear  about  it.  The  parent  nucleus,  as  Virchow  called  the  first  eruption, 
rapidly  extends,  the  skin  swells  about  it,  becomes  indurated,  livid,  and  hard. 
The  subcutaneous  tissues  are  extensively  infiltrated  with  serum.  The  appear- 
ance is  characterized  as  a  "  brawny  oedema,"  wdiich  rapidly  spreads  to  involve 
a  mass  of  tissue,  the  whole  of  one  arm  or  of  one  side  of  the  neck,  in  the  course 
of  a  few  days.  Lymphangitis  and  swelling  of  the  lymph-glands  with  phlebitis 
are  frequent  complications.  For  the  first  day  or  two  there  may  be  no  disturb- 
ance of  the  general  health.  The  patient  may  even  continue  at  w^ork,  but  toxic 
signs  set  in,  as  a  rule,  by  the  end  of  the  second  day  with  delirium,  diarrhoea, 
sweating,  vomiting,  and  collapse,  and  so  the  patient  may  die  of  heart  failure 
in  five  to  eight  days.  This  result,  however,  is  not  so  frequent  as  was  formerly- 
supposed.  In  the  majority  of  cases  the  local  inflanmiation  begins  to  abate  in 
the  course  of  a  few  days.  The  anthrax  sloughs  off  and  the  subjacent  ulcer 
closes  over  by  granulation. 

A  subvariety  of  this  condition  was  first  described  by  Bollinger  as  anthrax 
oedema.  In  this  form  the  local  lesion  is  absent.  Tiic  poison  seems  to  be 
introduced  more  deeply  into  the  tissues,  and  chemical  products  produce  an 
oedematous  state  of  wide  area.  This  variety  is  most  often  noticed  in  the 
region  of  the  eyelids. 

The  internal  mycosis  announces  itself  more  distinctly  as  an  infection.  The 
disease  begins  suddenly  with  chill,  pain  in  the  head  and  joints,  vomiting,  and 
diarrhoea.  The  case  looks  like  a  poisoning,  which  it  is.  Free  haemorrhage 
may  occur  from  the  mouth,  nose,  and  kidneys.  Nearly  always  (excei)tions 
being  noted  by  Bouisson)  there  is  an  outbreak  upon  the  skin  of  small,  |)lileg- 
monous,  carbuncular  inflammations,  the  so-called  metastatic  carbuncles.  Ti)ere 
is  jisually  but  little  fever.  Tiiere  may  be  much  delirium,  convulsions,  some- 
times oj)isthotonos.  There  is  often  precordial  anxiety  and  intense  dyspnoea. 
Cyanosis  and  heart  failure  usually  precede  the  termination,  which  may  occur 
in  the  course  of  a  very  few  days. 

Where  tlie  disease  originates  in  the  chest,  respiration  soon  becomes  difficult, 

though  auscultation  reveals,  as  a  rule,  only  the  signs  of  a  light   bronchitis. 

Diarrhfjca  is  usually  absent.     The  nervous  system  may  be  depressed  or  so  little 

affected  as  to  lead  jjatients  to  decline  medical  advice  even  a  few  hours  bcibro 

Vol..  I.— .'?i 


482  ANTHRAX. 

death.  The  case  bears  the  aspect  of  a  rapidly-spreading  pneumonia  with  heart 
faikire.  Most  of  these  cases  succumb  in  three  to  five  days.  Bell  declares  that 
they  who  survive  for  a  week  recover.  This  form  of  the  disease  has  been 
observed  more  especially  among  the  sorters  of  wool.  Most  of  the  fatal  cases 
have  been  hitherto  unrecognized.  Bell  thinks  that  many  of  the  cases  diagnos- 
ticated as  pneumonia,  bronchitis,  congestion  of  the  lungs,  etc.,  occurring  among 
workers  in  carpets,  blankets,  furs,  etc.,  are  really  cases  of  thoracic  anthrax. 
It  is  not  improbable  that  some  of  the  cases  ascribed  to  poisoning  by  mush- 
rooms, meat  ptomaines,  etc.  are  really  cases  of  intestinal  anthrax. 

Diag-nosis. — Anthrax  is  distinguished  by  its  origin  as  a  red  papule  with  a 
'dark  centre  and  its  rapid  extension  with  brawny  oedema.  The  black  central 
crust  is  absent,  and  any  extensive  surrounding  inflammation  is  absent  in  a 
common  boil  or  furuncle.  Carbuncles  show  themselves  much  more  frequently 
on  the  back  of  the  neck,  trunk,  and  extremities ;  anthrax  occurs  on  uncovered 
surfaces.  Anthrax  spreads  from  one  central  point  or  parent  nucleus;  carbun- 
cle results  from  the  coalescence  of  a  number  of  points.  Anthrax  oedema  in 
the  absence  of  a  central  papule  is  distinguished  by  its  sudden  appearance,  its 
yellowish-green  hue,  and  septic  symptoms.  Erysipelas  is  more  superficial, 
has  no  anthrax  or  parent  nucleus,  and  shows  no  bacteria  in  the  blood. 

The  diagnosis  of  intestinal  and  thoracic  anthrax  is  sometimes  reached  only 
by  exclusion  :  the  nature  of  the  avocation,  the  exposure  to  the  cause,  is  the 
most  common  index  to  the  condition.  The  sudden  occurrence  in  the  midst  of 
health  of  the  intense  signs  of  a  grave  infection — headache,  nausea,  and  vom- 
iting, dyspnoea,  cyanosis,  convulsions,  free  hseniorrhage,  especially  skin  car- 
buncles— in  connection  with  the  history  of  the  exposure,  should  lead  to  the 
recognition  of  the  disease.  In  any  case  of  doubt  the  diagnosis  may  be  estab- 
lished by  the  examination  of  the  blood  under  the  microscope  or  by  a  physio- 
logical test.  A  rabbit,  guinea-pig,  or  a  mouse  shows  dyspnoea,  dilatation  of 
the  pupils,  and  convulsions,  with  death  in  the  course  of  two  or  three  days  after 
inoculation.     The  blood  of  these  animals  swarms  with  bacilli. 

The  prog-nosis  is  always  grave ;  that  of  malignant  pustule  depends  upon 
the  stage  of  its  recognition.  The  disease  can  be  always  eradicated  at  first.  In 
places  where  its  picture  is  familiar  and  where  the  disease  is  attacked  at  once, 
the  mortality  is  reduced  to  5  or  9  per  cent.,  and  even  this  mortality  is  ascribed 
to  delay  in  treatment.  Under  neglect  the  mortality  may  reach  50  to  60  per 
cent.  Intestinal  and  thoracic  anthrax,  being  recognized  only  after  general 
infection,  have  always,  at  least  at  present,  a  fatal  prognosis. 

Prophylaxis  consists  in  the  proper  disposition  of  the  bodies  of  dead  animals 
by  deeper  burial  or  by  cremation  ;  in  the  avoidance  of  the  use  of  the  hides  or 
other  products  of  these  animals ;  in  the  destruction  of  their  discharges,  as  by 
fire;  in  shutting  off  affected  pasture-fields,  damming  up  streams  of  water, 
etc. ;  in  the  abundant  use  of  disinfectants — carbolic  acid,  chloride  of  lime,  cor- 
rosive sublimate — in  handling  suspected  wools,  horn,  and  other  products;  and 
in  the  protective  inoculation  of  cattle  and  sheep  with  attenuated  cultures  or 
antitoxines. 


TREA  TMENT.  483 

Treatment  must  be  radical.  Every  local  manifestation  must  be  attacked 
promptly  and  powerfully.  Before  absorption  a  diseased  mass  may  be  excised, 
or  incised  as  by  crucial  incision,  and  thoroughly  and  profoundly  cauterized, 
by  the  actual  cautery,  by  caustic  potash,  or  by  a  concentrated  solution  of  car- 
bolic acid  or  corrosive  sublimate.  Carbolic  acid  may  also  be  injected  subcu- 
taneously — 5  to  10  per  cent,  solutions — especially  in  a  case  of  anthrax  oedema. 
Cauterized  surfaces  should  be  dressed  with  weaker  solutions  of  these  or  similar 
antiseptics,  as  of  iodized  phenol,  1  :  100,  or  creolin,  1  :  50. 

Camera  best  expresses  the  principle  of  treatment  with  the  most  successful 
practice  in  countries  where  the  condition  is  most  frequently  encountered,  as 
follows:  The  mass  is  to  be  circumscribed  by  a  deep  incision  and  penetrated 
by  numerous  crucial  incisions.  In  the  bottom  of  all  these  cuts  is  to  be  strewn 
corrosive  sublimate  itself  in  powder,  gr.  0.04-0.15.  The  liquefaction  of  the 
sublimate  produces  extensive,  thoroughly  penetrating  destruction  of  the  entire 
mass.  Where  the  surface  is  so  great  as  to  lead  to  the  fear  of  poisoning  by  the 
sublimate  itself,  its  action  may  be  modified  and  poisoning  prevented  by  admix- 
ture with  a  proportion  of  calomel.  Weil  first  anesthetizes  the  mass  \\\\\\ 
cocaine,  scoops  it  out,  and  applies  to  the  wound  dressings  saturated  with  a  1 
per  cent,  solution  of  corrosive  sublimate.  Contento  injects  into,  under,  and 
about  the  mass,  subcutaneously,  3  per  cent,  solutions  of  carbolic  acid.  In  the 
ojdematous  form  the  whole  infiltrate  must  be  abundantly  scarified,  cut  deep 
down  to  the  healthy  tissue  in  the  same  way,  and  dressed  in  solutions  of  iodine 
and  carbolic  acid. 

In  cases  of  general  infection  metastatic  carbuncles  are  to  be  treated  in  the 
same  way,  and  the  patient  supported  with  brandy  or  subcutaneous  injections 
of  ether,  camphor,  or  other  analeptic.  Defi)rmities  about  the  nose  and  lips, 
which  may  follow  destruction  of  tissue,  may  be  subsequently  relieved  by  jilas- 
tic  operations. 

The  therapy  of  internal  anthrax  is  wellnigh  hopeless.  Where  it  is  known 
that  poisoned  meat  has  been  ingested,  the  stomach  should  be  immediately 
washed  out  or  a  powerful  emetic  administered,  followed  by  a  purgative  dose 
of  castor  oil.  For  an  internal  mycosis  it  has  been  recommended  to  administer 
carbolic  acid  in  doses  of  3  to  5  drops  three  or  four  times  a  day.  It  might  be 
better  to  saturate  the  blood  with  creasote,  as  in  the  treatment  of  the  sepsis  of 
tuberculosis,  and  with  alcohol,  as  in  ])oisoning  by  snake-bites.  Not  much 
hope  is  to  be  entertained  of  either  plan.  The  hope  which  seemed  justified  by 
the  experiments  of  Fodor  regarding  protection  by  saturation  of  the  blood  with 
an  alkali  has  proven  futile,  according  to  the  subsequent  investigations  of  Chor. 
Future  success  must  be  obtained  i)y  means  of  toxincs  or  antitoxines.  llankin 
of  Cambridge  finds  defensive  proteids  in  the  serum  of  the  blood  of  certain 
animals.  There  is  a  protective  albuminoid,  a  non-dialyzablc  globulin,  insol- 
uble in  alcohol  and  water,  in  the  blood  and  spleen  of  a  rat,  which  nMuicrs  a 
mouse  immune  against  the  most  violent  anthrax.  The  same  matter  from  sus- 
ceptil)le  animals  has,  however,  nuich  less  destructive  elTcit,  and  does  not  confer 
the  same  immunity  upon  mice.     Wild  rafs,  whi<-h  enjoy  natural  immunity,  lose 


484  ANTHRAX. 

it  when  put  upon  a  diet  of  bread,  and,  losing  it,  lose  also  protective  proteids  in 
the  blood.  Very  young  rats,  which  are  susceptible  to  anthrax,  contain  only 
traces  of  the  protective  proteids.  Kostjurin  and  Krainsky  reached  the  con- 
clusion that  certain  toxines  from  decomposition,  introduced  at  the  proper  time 
into  the  bodies  of  rabbits  affected  with  anthrax,  totally  prevent  the  develop- 
ment of  the  disease.  The  toxines  must  be  obtained  from  decomposing  extracts 
freshly  prepared  and  well  protected  against  the  influence  of  light  and  air,  else 
they  inhibit,  but  do  not  prevent,  the  development  of  the  disease.  The  injection 
must  be  made  in  five  to  eight  hours  after  the  inoculation,  though  it  may  be 
sometimes  effective  after  twenty-four  hours.  More  perfect  results  are  obtained 
by  repetition  of  the  injection  on  the  third  or  fourth  day.  The  dose  for  the 
first  injection  is  0.1  gr. ;  for  repeated  injections,  half  of  this  amount,  0.05  gr. 
The  essential  principle  in  the  extract  is  not  the  product  of  a  definite  micro- 
oro-anism,  but  a  number  of  them.  The  addition  of  the  smallest  amounts 
(0.1-1  per  cent.)  to  the  culture  media  totally  destroys  the  virulence  of  anthrax 
bacteria  without  in  the  least  hindering  vegetation. 

Ogata  and  Jasuhara  claim  that  the  blood  of  immune  animals — e.  g.  dog 
and  fowl — contains  a  ferment  which,  injected  subcutaneously  in  but  one-  or 
two-drop  doses,  acts  as  a  certain  preventive  and  curative  remedy.  This  fer- 
ment also  prevents  the  development  of  the  cholera  and  typhoid  bacillus. 

These  disclosures  of  much  promise  have  not  yet  been  utilized  in  the  treat- 
ment of  anthrax  in  man. 


HYDROPHOBIA. 

By  JAMES  T.  WHITTAKER. 


Hydrophobia  (ixJcop,  water,  (f<6[:ioz,  fear) ;  Gi-eek,  Lyssa,  Xuaaa,  rage ; 
Latin,  Rabies  ;  French,  La  rage  ;  German,  Wuth,  Hundswuth  ;  Italian,  Rab- 
bia;  Swedish,  Hundsjuka, — is  an  intensely  virulent  infection  of  the  lower  ani- 
mals— dog,  fox,  wolf,  cat,  and  skunk,  in  the  order  of  decreasing  frequency — 
communicable  also  to  man,  having  the  most  variable,  often  the  longest  known, 
period  of  incubation.  It  is  distinguished  by  melancholia,  terror,  intense  hy- 
peraesthesia  of  the  medulla,  evinced  as  a  spasm  of  the  pharynx  and  larynx 
excited  by  attempts  to  swallow  or  the  presence  or  the  mere  thought  of  liquids, 
and  a  subsequent  very  short  stage  of  paralysis,  and  almost  inevitable  death. 

The  name  is  appropriate  as  expressing  the  most  prominent  symptom  of 
the  disease  in  man,  but  is  inappropriate  for  the  lower  animals,  as  precisely  this 
symptom,  the  fear  of  water,  so  obtrusive  in  man,  is  in  them  entirely  absent. 
Emphasis  should  be  laid  upon  this  point  at  the  start.  The  gravest  errors  have 
arisen  in  consequence  of  ignorance  or  disregard  of  it.  Rabid  dogs  have  been 
considered  safe  because  they  drank  water.  Rabid  dogs  love  water.  Rabies  is 
with  them  a  hydrophilia  rather  than  a  hydrophobia. 

It  is  strange  that  while  the  disease  appears  to  have  been  known  to  the 
ancient  Indians,  Egyptians,  and  Israelites,  Hippocrates  makes  no  mention  of 
it.  Aristotle  (322  b.  c.)  recognized  it  unmistakably  in  dogs  :  "  Dogs  suffer 
from  rabies.  This  induces  a  state  of  madness,  and  all  animals  who  are  then 
bitten  by  them  are  likewise  attacked  by  rabies."  Democritus  considered  it  an 
inflammation  of  the  nerves  allied  to  tetanus.  It  is  mentioned  by  Virgil, 
Horace,  Ovid,  Plutarch  (130  b.  c).  Celsus,  who  first  uses  the  word,  speaks  of 
it  as  the  disease  which  ''  udo)fj(fOj3cav  Grceci  oppellnnt."  The  wound  should  be 
sucked  out,  he  says,  by  means  of  dry  cups,  and  should  be  afterward  destroyed 
by  the  actual  cautery.  If  the  wound  be  not  so  treated,  hydrophobia  ensues — 
"a  most  deplorable  malady,  one  in  which  no  hope  of  recovery  can  be  enter- 
tained." Galen  declares  hydrophobia  to  be  the  worst  of  all  diseases,  and 
recommends  excision  of  the  wound  in  protection  against  infection.  Cfclius 
Aurclianus  discusses  its  modes  of  origin  and  absorption,  the  differential 
diagnosis  from  inflammation  of  the  brain  and  mania,  the  course  of  the  dis- 
ease, and   its  treatment. 

A  thorough  elaboration  of  the  symptomatology  in  tiie  lower  animals  as  well 
as  in  man  is  chiefly  due  to  English  observers,  especially  to  Youatt.  Pasteur  has 
connected  his  name  with  hydrophobia  for  all  time  by  his  studies  of  prophy- 
laxis— studies  which  established  the  nature  of  the  disease  as  an  infection  whose 

48J 


486  HYDROPHOBIA. 

symptoms  are  clue  to  toxines  from  some  as  yet  undiscovered  micro-organism, 
and  which  fixed  the  fact  of  the  first  importance  that  rabies  may  in  no  case 
arise  spontaneously,  but  always  and  only  from  itself. 

Hydrophobia,  like  syphilis,  is  communicated  by  inoculation  through  a 
broken  skin,  and,  while  it  may  be  transmitted  by  any  animal,  it  is  actually 
communicated  to  man  in  the  great  majority  of  cases,  90  per  cent,,  by  the  bites 
of  rabid  dogs.  It  is  therefore  essential  to  a  true  understanding  of  rabies,  as 
well  as  to  the  prevention  of  the  disease,  that  some  knowledge  should  be  had 
of  its  main  features  in  the  dog.  Rabid  dogs  are  mad,  but  mad  dogs  are  not 
necessarily  rabid.  Mad  dogs  may  be  only  angry  or  insane,  for  dogs  are  very 
near  to  man  in  nervous  organization.  The  popular  idea  that  a  dog  in  a  fit 
is  mad  is  wrong.  Epilepsy  is  not  rabies.  The  idea  that  rabies  is  more  com- 
mon in  summer  is  not  incorrect,  though  the  ratio  of  cases  is  not  greater  than 
7  to  15  per  cent.,  and  this  increase  is  not  due  to  temperature,  but  solely  to  the 
increased  number  of  inoculations.  It  is  a  period  of  rivalry  and  wrangling, 
intensely  heightened  by  the  cruel  disproportion  of  sex.  The  preponderance 
of  male  dogs  affected  (10  to  1)  has  always  been  observed,  and  is  readily  under- 
stood, for  dogs  are  actually  more  considerate  to  their  females  than  are  men. 
It  is  now  known,  however,  that  rabies  is  not  due  to  lack  of  sexual  congress. 

Habies  is  communicated  by  the  saliva,  but  is  not  confined  to  that  secretion. 
Paul  Bert  found  bronchial  mucus  virulent.  Eckel  and  Lafosse  communicated 
the  disease  with  the  inoculation  of  blood — Lafosse  from  dog  to  dog,  Eckel  from 
goat  to  sheep  and  from  man  to  dog.  Saliva  has  been  repeatedly  successfully 
inoculated  from  numerous  animals,  as  by  Berndt  from  ox  to  sheep,  by  Eckel 
from  goat  to  sheep,  Rey  from  sheep  to  sheep,  Lessone  from  ox  to  horse  and 
sheep,  Youatt  from  horse  and  ox  to  dogs,  and  Ashburner  from  ox  to  fowls. 
King  from  cow  to  fowls,  Earle  from  man  to  rabbits,  Majeudie  and  numerous 
other  observers  from  man  to  dog.  The  disease  has  been  communicated  acciden- 
tally from  horse  to  man,  from  sheep  to  shepherd,  and  from  man  to  man  (Law). 

The  average  period  of  incubation  in  the  dog  is  from  thirty  to  fifty  days. 
It  varies,  however,  from  six  to  two  hundred  and  forty  days.  It  is  certain 
that  the  animal  may  communicate  the  disease  during  the  whole  of  the  period 
of  incubation.  As  a  rule,  there  are  no  symptoms  until  the  end  of  it,  when 
there  is  observed  some  change  in  the  disposition  ;  and  any  change  of  this  kind 
is  to  be  regarded  with  suspicion.  In  some  cases  there  is  unusual  dulness  and 
indifference,  and  in  other  cases  unusual  vigilance  and  nervousness.  A  morbid 
appetite,  which  leads  the  animal  to  pick  up  foreign  bodies  or  devour  its  own 
excrement,  is  very  characteristic.  A  dog  which,  hitherto  affectionate,  becomes 
morose  and  resentful  should  be  regarded  with  distrust.  Per  contra,  a  sudden 
excess  of  affection  in  a  dog  hitherto  lacking  in  this  regard  may  betray  the  dis- 
ease. If  a  social  dog  seeks  seclusion  or  bears  punishment  without  a  cry,  he  is  to 
be  strongly  suspected.  "  Barking  without  object,  constant  moving  and  search- 
ing and  scraping,  a  disposition  to  tear  wood,  clothing,  etc.  to  pieces,  and,  above 
all,  absence  from  home  for  a  day  or  two,  should  beget  grave  apprehensions" 
(Law).     A  dog  in  this  stage  of  rabies  is  in  a  state  of  suppressed  excitement, 


SYMPTOMA  TOL  OGY.  487 

to  which,  with  uplifted  head,  he  gives  vent  from  time  to  time  in  a  hoarse  and 
muffled  howl,  a  cross  between  a  bark  and  a  howl,  the  so-called  rabid  bark 
or  howl,  wherein  one  loud  sound  is  followed  by  several  others  in  diminishing 
force.  It  is  impossible  for  a  mad  dog  to  keep  (piiet;  he  must  wander;  lie 
makes  long  excursions,  it  may  be  of  many  miles,  flying  at  any  animal  or  man  he 
meets  as  if  possessed  by  demons.  In  a  state  of  evident  mania  he  is  seized  with 
paroxysms  of  wicked  fury  or  is  at  intervals  affected  with  evident  hallucina- 
tions. A  mad  dog  will  oflen  glare  into  vacancy,  then  suddenly  collect  him- 
self, as  from  some  horrid  dream,  with  a  violent  start,  jump  to  his  feet,  rapidly 
open  and  close  his  eyes,  wrinkle  his  forehead,  snarl  and  snap  at  an  imaginary 
foe,  or  viciously  attack  any  object,  animate  or  inanimate,  that  he  can  reach,  or 
he  will  gnaw  to  shreds  an  offending  paw  or  tear  off  j^arts  of  his  own  body.  He 
will  seize  and  hold  a  stick  of  wood  or  iron  bar  until  his  teeth  are  broken  or 
dislodo-ed.  Finallv,  exhausted  bv  his  efforts  or  in  the  further  course  of  the 
disease,  he  gradually  sinks  into  a  state  of  paralysis,  shown  first  as  a  para- 
plegia, a  weakness  of  his  hind  legs,  with  swaying  motion  in  walking,  and  by 
the  fall  of  the  lower  jaw,  which  permits  the  escape  of  viscid  saliva,  which 
he  still  makes  frantic  efforts  to  detach.  The  manifestation  of  ]>aralysis  pres- 
ages death,  which  occurs  in  the  course  of  eight  to  ten  days  from  the  beginning 
of  the  disease.  Throughout  this  whole  period  there  is,  as  stated,  never  any 
hydrophobia.  The  dog  suffers  intense  thirst,  which  he  attempts  to  allay  l)y 
plunging  his  head  in  water  and  lapping  every  fluid  he  meets,  including  his 
own  urine.  So  far  from  showing  aversion  to  water,  he  rather  seeks  it,  and 
in  his  journeys  will  swim  a  river  rather  than  turn  from  his  course. 

In  about  one-fifth  of  the  cases  the  second  stage — that  is,  the  rabid  stage — 
is  entirely  absent  in  the  dog.  The  disease  passes  at  once  from  melancholia 
to  paralysis.  In  tliese  cases  there  is  an  absence  of  the  desire  to  destroy  and 
to  bite,  as  well  as  of  the  impidse  to  wander  away.  Paralysis  may  set  in  in 
the  course  of  a  single  day,  to  show  itself  first  in  paresis  of  the  lower  jaw, 
which  drops  to  permit  the  more  or  less  constant  escape  not  only  of  saliva,  but 
also  of  everything  taken  into  the  mouth.  The  animal  is  at  first  able  to  close 
the  mouth  under  ])owerful  effort,  as  after  extreme  irritation,  but  rapidly  loses 
the  power  altogether.  Paraplegia  soon  sets  in,  and  the  animal  dies  within  two 
or  three  days. 

Timid  animals,  like  foxes  or  badgers,  lose  their  shyness;  wolves  become 
still  more  ferocious;  cats  are  less  liable  to  attack,  but  do  not  hesitate  to  use 
teeth  and  claws  on  occasions  ;  infected  horses  and  cattle  bite  and  kick,  and 
even  fowl  show  disposition  to  inflict  wounds  with  the  beak.  Animals  affected 
with  rabies  are  therefore  truly  said  to  be  "  mad." 

The  disease  prevails  verv  much  less  in  some  countries  than  in  others, 
though  statistics  in  the  same  country  vary  at  different  decades  or  centin-ics. 
Prevalence  or  absence  in  a  country  is  of  course  wholly  a  matter  of  introduction 
and  inoculation.  Thus,  hydrophobia  was  most  common  in  Prussia  in  the  last 
century,  in  one  decade  of  which  there  were  reported  1()G()  deaths,  whereas  at  the 
present  time  the  disease  is  actually  nid<n.)\vu  in  that  country,  owing  to  the  rigid 


488  HYDROPHOBIA. 

enforcement  of  muzzling  dogs.  The  disease  was  formerly  very  rare  in  France. 
Trousseau  declared  that  in  his  time  there  were  not  two  cases  for  each  million 
of  inhabitants.  It  is  now  more  frequent,  partly,  of  course,  on  account  of  the 
importation  of  cases  for  treatment  at  a  stage  too  late  to  be  benefited.  There 
was  no  hydrophobia  in  the  isle  of  Cyprus  or  in  Tasmania  and  Madeira, 
countries  which  abound  in  curs  of  low  degree.  There  was  no  hydrophobia 
in  Cochin-China  up  to  1880,  since  which  time  the  disease  has  become  so  fre- 
quent as  to  justify  the  establishment  of  a  Pasteur  institute  for  its  treatment. 
The  disease  is  very  rare  in  South  America,  and  is  by  no  means  common  in 
England  or  in  our  country.  Watson  declares  that  many  physicians  have  never 
seen  a  case.  But  three  cases  have  occnrred  in  the  practice  of  the  author  in  a 
quarter  of  a  century. 

Ninety  per  cent,  of  cases  are  contracted  by  the  bite  of  a  dogj  but  not  every 
case  bitten  by  a  dog  turns  out  to  be  hydrophobia.  A  bite  from  an  animal 
which  is  simply  eni-aged,  maniacal,  or  epileptic  cannot,  of  course,  convey  the 
disease.  The  mere  fact  that  a  dog  has  fits  excludes  the  diagnosis  of  hydro- 
phobia, which  never  shows  convulsions,  though  most  dogs  thus  affected  are 
accused,  persecuted,  and  killed.  Hence  the  proverb,  "■  Give  a  dog  a  bad 
name,"  etc.  The  majority  of  individuals  bitten  by  a  dog  actually  mad  escape 
the  disease.  This  is  especially  the  case  in  lesions  of  covered  surfaces.  The 
clothing  wipes  oft'  the  infection  with  the  saliva.  For  the  same  reason  most 
animals  escape,  the  infectious  matter  being  retained  in  the  hide  or  wool. 
Hence  bites  on  the  face,  neck,  or  hands  are  much  more  dangerous.  The 
bites  of  wolves  are  worse  than  those  of  dogs,  because  wolves  fly  at  the  face. 
It  is  estimated  that  47  per  cent,  of  persons  bitten  by  mad  dogs  suffer  hydro- 
phobia. A  difference  has  been  noticed  even  among  dogs.  As  an  instance, 
a  dog  was  bitten  by  thirty  different  mad  dogs  without  once  contracting  the 
disease. 

According  to  Youatt,  two-thirds  of  the  dogs  bitten  by  rabid  dogs  are 
affected  with  the  disease.  This  is  certainly  a  large  percentage.  Hertwig 
found  that  but  6  of  137  dogs  bitten  and  kept  under  his  observation  died 
from  hydrophobia,  while  all  the  rest  escaped  infection.  This  was  certainly  a 
small  percentage.  In  these  experiments  certain  dogs  resisted  infection  alto- 
gether. Hertwig  was  unable  to  produce  the  disease  in  19  of  30  dogs  either 
by  subjecting  them  to  bites  or  by  direct  inoculation.  Renault  found  that  he 
could  infect  but  67  per  cent,  of  his  dogs.  The  rest  remained  free  for  the 
hundred  days  in  which  they  were  kept  under  observation.  Hertwig  had  one 
dog  which  continually  resisted  the  disease,  though  it  was  inoculated  nine  times 
in  the  course  of  three  years.  Other  dogs  meanwhile  inoculated  were  attacked. 
Certain  animals  resist  two,  three,  or  even  four  inoculations,  and  then  finally 
succumb  to  a  last  trial. 

Escape  is  sometimes  due  to  accident.  A  bite  after  a  recent  bite  is  less  dan- 
gerous, because  saliva  may  have  been  wiped  off  in  the  first  bite.  The  danger 
is  illustrated  by  the  part  of  the  body  bitten.  In  some  American  statistics 
quoted  by  Watson,  of  75  cases  the  wound  was  in  the  hand  40  times,  on  the 


SYMPTOMA  TOLOa  V.—DIA  GNOSIS.  489 

face  15,  in  the  leg  11,  and  the  arm  9  times.  Of  495  ca:?es  collected  by  Bol- 
linger, 53  per  cent,  were  bitten  on  the  upper  extremities,  22  j)cr  cent,  on  the 
head  and  face,  22  per  cent,  on  the  feet,  and  3  per  cent,  on  the  body  and 
scrotum.  The  cures  of  the  charlatans  bv  so-called  mad  stones,  etc.,  often  of 
great  virtue  in  psychical  cases,  get  their  rejiutation  from  use  in  cases  which 
have  escaped  infection. 

The  period  of  incubation  of  hyclro})liol)ia  covers  a  point  of  the  most  intense 
and  anxious  interest.  How  long  after  a  bite  may  an  individual  be  considered 
safe?  This  is  the  point  in  which  hydrophobia  and  lepra  differ  from  other  dis- 
eases, in  that  the  period  of  incubation  is  so  indefinite.  In  the  majority  of  cases 
it  is  unusually  long.  Thus,  in  60  per  cent,  the  period  of  incubation  varies  from 
eighteen  to  sixty  days,  but  in  34  per  cent. — that  is,  in  a  little  more  than  one- 
third  of  all  the  cases — the  period  is  longer  than  two  months.  Abundant  cases 
are  upon  record  of  outbreak  of  the  disease  only  after  the  lapse  of  three  to 
six  months,  and  there  are  cases  upon  authentic  record  where  the  only  exposure 
which  could  have  accounted  for  the  disease  occurred  one  year,  or  even  more 
than  two  years,  before  the  attack.  In  a  very  small  ratio  of  cases  (6  to  18  per 
cent.)  the  period  of  incubation  is  short,  from  three  to  eighteen  days.  Some- 
times these  alleged  long  periods,  as  well  as  cases  without  apparent  cause,  find 
explanation  in  a  more  recent  infection  which  has  been  overlooked  or  forgotten. 
Thus,  Youatt  traced  one  case  in  a  man  to  an  attempt  to  untie  with  the  teeth  a 
knot  in  a  cord  which  had  been  used  to  confine  a  mad  dog ;  another  in  a  woman 
to  the  use  of  her  teeth  to  press  down  the  seam  in  mending  a  tear  in  her  dress 
where  it  M^as  caught  by  a  rabid  animal.  Wiien  it  is  remembered  that  the 
whole  period  of  incubation  in  dogs  is  infectious,  even  though  the  animal  show 
no  signs  of  the  disease,  it  may  be  understood  how  frequent  are  the  possible 
sources  of  infection. 

Variation  in  the  time  of  outbreak  has  been  distinctly  observed  in  dogs. 
On  one  occasion  six  dogs  bitten  by  one  rabid  animal  showed  signs  of  the 
disease  respectively  in  twenty-three,  fifty-six,  sixty-seven,  eighty-eight,  one 
hundred  and  fifty-five,  and  one  hundred  and  eighty-three  days. 

In  civilized  countries  the  disease,  as  stated,  is  nearly  always  propagated  by 
dogs.  In  semi-civilized  countries,  as  in  Russia,  Galatia,  etc.,  it  may  be  caused 
more  frequently  by  wolves  ;  in  the  East  Indies,  by  jackals.  Taking  the  statistics 
from  France,  Wurtemberg,  and  Milan  of  796  human  beings,  715  were  bitten 
by  dogs,  30  by  cats,  31  by  wolves,  19  by  foxes,  and  1  by  a  cow. 

The  diagnosis  of  the  disease  is  nnich  more  difficult  in  the  dog  than  in 
man.  The  change  of  disposition,  the  desire  to  wander,  the  peculiar  howl,  arc 
cardinal  points.  In  a  doubtful  case  the  diagnosis  may  l)e  made  to  rest  largely 
upon  the  condition  of  the  stomach  fi)und  after  the  death  ol'  the  animal,  for  it 
is  declared  that  if  the  stomach  and  small  intestine  ap])ear  healthy  and  contain 
normal  fi)od,  the  animal  may  be  considered  free  of  hydroi)hobia.  If,  however, 
the  stomacli  be  foiuHl  full  df  indigestible  fi)reign  matter,  its  mucous  membrane 
s])otted  w  ith  hiemorrliages,  the  larynx  and  pharynx  hyperoomic  or  inllamed, 
therf'  is  stron<'-  evidence  of  iiydrophobia.      l>att  insists,  however,  that  tliis  con- 


490  HYDROPHOBIA. 

dition  of  the  stomach  is  often  found  in  or  after  other  diseases,  and  that  a 
diagnosis  may  not  be  declared  from  post-mortem  evidence  alone. 

From  almost  the  first  recognition  of  the  disease  in  man  attempts  have  been 
made  from  time  to  time  to  deny  its  existence  altogether,  and  to  consider  hydro- 
phobia a  fright  and  form  of  hysteria  or  of  tetanus.  The  fact,  however,  to  say 
nothing  of  inoculation  experiments  in  animals,  that  so  many  children  under 
the  ao-e  of  five — 9  per  cent,  of  all  cases  in  France — and  so  many  idiots  and 
imbeciles,  in  whom  the  imagination  could  play  no  role,  have  succumbed  to  the 
disease,  sufficiently  disproves  this  view.  The  symptoms,  as  will  be  seen,  dis- 
tinctlv  differ  from  tetanus,  and  the  most  that  may  be  said  of  the  hysterical 
origin  is  the  fact  that  hysteria  may  simulate  hydrophobia  or  any  other 
disease. 

Notwithstanding  the  searching  investigations  at  the  hands  of  the  best 
observers,  especially  in  connection  with  the  study  of  prophylaxis,  the  cause 
of  hydrophobia  remains  unknown.  The  analyses  of  chemistry  have  failed  to 
disclose  it.  No  specific  micro-organism  has  been  detected  in  the  saliva  or 
other  fluid,  and  no  distinct  toxine  has  been  eliminated  from  any  of  the  secre- 
tions or  tissues  of  the  body.  The  poison  is  in  all  cases  fixed,  never  volatile. 
It  is  produced  only  within  the  body,  never  outside  of  it.  It  acts  in  every 
respect  like  a  chemical  poison  which  is  evolved  from  micro-organisms,  but 
differs  from  all  the  known  poisons  by  the  length  of  time  in  which  it  may 
remain  innocuous  in  the  body.  Other  secretions  than  the  saliva,  as  well  as 
the  flesh  of  animals,  as  a  rule,  fail  to  convey  the  disease.  Though  the  poison 
is  in  the  cord,  the  cerebro-spinal  fluid  is  not  infectious  (Wyssokowicz) ;  the 
aqueous  humor  is  certainly  not  infectious  (Cardelli) ;  the  gastric  juice  destroys 
all  virus  (Wyrskowski),  as  is  shown  by  the  fact  that  a  fox  ate  without  dam- 
age the  cords  of  several  affected  foxes  and  dogs  (Nocard). 

The  poison  of  hydrophobia  (rabies)  is  certainly  fixed  in  the  nervous  system 
in  the  large  nerves,  and  especially  in  the  medulla,  and  eminently  in  the  salivary 
glands.  Introduction  of  matter  from  these  tissues  directly  into  the  brain  (dura) 
develops  the  disease  in  from  two  to  seven  days;  introduction  into  other  parts 
of  the  body  develops  the  disease  only  after  a  long  interval — one  to  six  months 
— as  after  bites  of  rabid  animals.  Whether  the  blood  be  infectious  is  a  ques- 
tion upon  which  authorities  are  nearly  evenly  divided.  It  is  probable  that  the 
blood  is  infectious  only  for  a  short  time,  and  that  it  then  secretes  the  poison  in 
the  nervous  tissue.  The  injection  of  large  quantities  of  a  concentrated  virus 
directly  into  the  blood  not  only  does  not  infect  large  animals  (sheep  and 
goats),  but  actually  protects  them  against  inoculation  even  after  trephining. 
Roux,  Nocard,  and  Protopopow  confirm  this  fact  and  propose  to  utilize  it 
in  prophylaxis.  Helmann  found  that  the  introduction  of  concentrated  virus 
into  the  subcutaneous  tissue  not  only  did  not  infect,  but  absolutely  gave  im- 
munity to,  dogs,  moid-ceys,  and  even  rabbits.  Thereupon,  Ferran  ventured 
to  inject  as  much  as  40  ccm.  of  the  "virus  fixe"  into  the  subcutaneous  tis- 
sue of  man  in  the  treatment  of  hydro]>hobia.  Pasteur  found  such  injections 
sometimes  fatal  to  dogs,  and  Celli  succeeded  in  producing  rabies  in  ten  to 


MORBID    ANATOMY.  491 

twenty  clays  after  the  introduction   of   the  cord   of  rabid  animals   into   the 
peritoneal   sac  of  rabbits. 

Various  theories  have  been  proposed  to  account  for  the  long  latency  of  the 
disease — to  wit:  First,  the  virus  inoculated  remains  latent  at  the  wound  until  it 
may  accumulate  to  sufficient  extent  to  inundate  the  blood  and  the  body.  This 
view  would  seem  to  iind  support  in  the  prevention  of  the  disease  by  the  exsec- 
tion  or  destruction  of  the  wound  ;  but  the  fact  that  the  disease  may  be  con- 
veyed at  any  time  during  the  period  of  incubation  is  a  sufficient  refutation  of 
it.  Second,  that  the  poison  is  not  taken  up  by  the  lymphatics  about  the  blood- 
vessels, but  travels  slowly  along  the  course  of  nerves  until  it  finally,  in  the 
course  of  weeks  or  months,  reaches  the  central  nervous  system.  This  mode 
of  invasion  has  been  more  frequently  considered  in  tetanus.  Einhorn  went 
so  far  as  to  declare  that  he  had  been  able  to  trace  up  a  line  of  inflammation 
along  the  course  of  the  ulnar  nerve  in  a  case  of  hydrophobia.  The  nerves 
on  the  bitten  side  contain  more  virus  than  those  on  the  sound  side  (Roux). 
Third,  the  poison  lies  latent  at  the  wound,  and  from  it  chemical  products  are 
gradually  introduced  into  the  blood,  but  are  neutralized  from  time  to  time  by 
the  serum  of  the  healthy  blood,  by  the  so-called  protective  proteids  which  act 
as  antitoxines  or  antidotes,  until  finally  they  fail  to  permit  intoxication.  This 
view  has  now  the  best  support.  It  accounts  for  the  esca})e  of  so  many  cases, 
with  the  simultaneous  infection  of  others.  It  furnishes  an  explanation  of  the 
fact  that  the  bite  of  a  dog  in  the  stage  of  incubation  may  be,  but  is  not  always, 
infectious.  It  accounts  also  for  the  favorable  influence,  even  to  the  prevention 
of  the  disease,  of  the  destruction  of  it  at  its  origin.  It  allies  it  with  other  poi- 
sons, as  in  a  case  of  septicaemia,  where  the  removal  of  a  local  depot  may  put 
a  stop  to  a  long  train  of  septic  signs.  This  view  is,  however,  only  a  theory  as 
yet.  It  is  claimed  by  the  Pasteur  school  that  exsection  and  cauterization  will 
not  prevent  infection,  any  more  than  such  treatment  will  prevent  vaccination. 
Escape  from  infection  in  this  doctrine  means  failure  of  inoculation. 

Morbid  Anatomy. — Notwithstanding  the  tempestuous  and  terrible  signs 
of  the  disease,  little  or  no  lesion  may  be  discovered  upon  autopsy.  The  symp- 
toms are  explained  by  the  action  of  a  virulent  chemical  poison  which  does  its 
work,  disappears,  and  often  leaves  no  trace.  The  negative  evidence  thus  en- 
countered is  testimony  of  great  value.  Some  signs  of  catarrhal  inflammation 
are  usually  to  be  seen  in  the  throat,  more  especially  in  the  larynx.  The  lungs 
show  both  hyperemia  and  oedema.  Spots  of  ecchymosis  are  sometimes  found 
in  the  pericardium  and  heart.  The  kidneys  are  deejily  injected  ;  the  e})ithelial 
lining  of  the  tubules  is  more  or  less  opaque,  and  sometimes  shows  molecular 
degeneration.     The  blood  is  black  and  thick. 

The  only  really  important  changes  are  encountered  in  the  brain,  and  very 
frequently  they  are  entirely  lacking.  On  removal  of  the  calvariinn  the  brain 
is  found  wet.  The  longitudinal  sinus  is  filled  to  distension  with  fluid,  black 
blood.  Sometimes  there  is  evidence  everywhere  of  extensive  hyper.Tmia. 
The  only  changes  which  can  be  said  to  be  at  all  characteristic  are  microscoi)ic, 
and  tluiv  are,  with  the  rest,  sometimes  entirely  absent.     The  suiall  vessels  are 


492 


HYDR  OPHOBIA . 


dilated,  and  invested  upon  their  exterior  with  leucocytes  which  invade  also  the 
circumjacent  tissues.  These  changes  are  most  marked  in  the  medulla  and 
the  upper  part  of  the  spinal  cord,  as  well  as  in  the  cerebral  cortex,  whence  the 
symptoms  of  hydrophobia  arise.  (See  Figs.  32,  33.)  Gowers  observed  this 
condition  in  7  of  9  cases.  Emigration  or  accumulation  of  leucocytes  is  at 
times  so  great  as  to  fill  up  the  whole  space  within  the  lymphatic  sheath. 


Fig.  32. 


Fig.  33. 


,  f.//"f 


m% 


mwmmii^^^ 


Fig.  32.— Hypoglossal  Nucleus :  leucocytes  around  a  vessel  and  extending  into  the  adjacent  tissue 
(Gowers). 

Fig.  33.— Accumulation  of  Corpuscles  ("miliary  abscess")  in  the  Fibres  of  Origin  of  the  Hypoglossal 
Nerve  (Gowers). 


The.se  escaped  and  accumulated  cells  constitute  what  may  be  called  miliary 
absces.ses.  In  association  with  them  are  observed  at  times  small  heemorrhages, 
seldom  large  enough  to  be  visible  to  the  naked  eye.  This  perivascular  accu- 
mulation of  leucocytes,  especially  in  connection  with  the  vessels  of  the  medulla 
and  cortex,  constitutes  the  most  constant  and  characteristic  lesion  of  hydro- 
phobia. Unfortunately,  as  .stated,  this  sign,  with  all  the  rest,  is  sometimes 
entirely  absent. 

Symptomatolog-y. — Hydrophobia  is  divided  into  three  stages — the  melan- 
cholic, spasmodic,  and  paralytic.  The  disease  is  usually  announced  by  changes 
at  the  seat  of  the  wound,  which,  as  a  rule,  has  long  since  healed.  There  is,  it 
may  be  said,  nothing  in  the  nature  or  course  of  the  healing  process  in  an  in- 
fected different  from  that  in  a  simple  wound.  The  bite  of  a  mad  dog  heals  as 
quickly  and  kindly  as  that  of  a  healthy  dog.  The  wound  may  .show  no  change 
from  the  beginning  to  the  end  of  the  disea.se.  Sometimes  no  trace  of  it  can 
be  discovered,  but  not  infrequently,  as  stated,  inflammatory  changes  set  in  at 
the  cicatrix,  which  may  become  reddened  or  swollen.  The  wound  may  open 
anew  or  become  the  seat  of  pain,  itching,  numbness,  or  other  parsesthesia. 
Sometimes  pain  i-adiates  from  it  in  various  directions.  Sometimes  the  first 
feeling  is  in  the  nose  or  throat,  a  sneezing,  a  dryness,  or  a  rawness  which  is 
considered  a  "  cold." 

A  peculiar  state  of  depression  or  irritability  .soon  sets  in,  sometimes  sud- 
denly, with  headache,  anorexia,  insomnia,  anxiety.  Mental  symptoms  assume 
])romincncc  according  to  the  temperament  of  the  individual.  A  man  may 
deny  the  fact  that  he  ever  was  bitten  by  a  doo;,  while  he  is  unable  to  divert 


.SVJirTOJfA  TOLOG  Y.  493 

his  mind  from  the  actual  occurreuce  and  the  terrible  consequences  which  are 
liable  to  ensue.  The  inquiry  or  suggestion  of"  a  thoughtless,  meddlesome,  or 
inquisitive  neighbor  will  plunge  the  strongest  man  into  melancholy  or  mania. 
The  mental  distress  is,  however,  always  an  exaggeration  of  a  state  of  appre- 
hension, of  a  sense  of  impending  danger  or  imminent  death,  and,  though  a 
man  may  show  under  the  stress  of  this  suffering  signs  of  insanity,  there  is  no 
time  when  he  may  not  be  recalled  to  himself  by  a  right  address.  A  patient 
affected  with  the  first  stage  of  hydrophobia  is  a  pitiful  })icture.  He  sits  quietly, 
apparentlv  listlessly,  his  whole  mind  intensely  concentrated  u})on  the  one  thought, 
from  which  no  a[)peal  or  address  may  really  divert  him.  It  is  only  in  the  very 
first  hours  of  the  attack  that  he  may  find  relief  in  walking  about  or  in  change 
of  scene.  He  soon  becomes  exhausted,  and  sits  with  an  expression  of  intense 
anxietv,  to  which  he  makes  total  surrender.  At  the  same  time,  the  special 
senses  are  keenly  alert,  so  that  a  flare  of  light,  a  draught  of  air,  a  noise, 
may  produce  intense  excitement.  The  very  first  day  shows  the  characteristic 
sign  of  the  disease,  the  fear  of  ^<^ater.  The  patient  suffers  with  thirst,  but  is 
unable  to  allay  it.  He  may  make  the  attempt,  may  succeed  at  first  in  swallow- 
ing a  mouthful  or  two,  but  soon  abandons  it,  either  on  account  of  the  intense 
suffering  which  ensues  or  from  the  fear  of  its  certain  following.  An  unmis- 
takable sign  of  the  disease  is  the  occurrence  of  burning,  more  especially  a 
sense  of  tightness  or  constriction,  of  the  larynx.  The  fear  of  water  is  the 
fear  of  exciting  s})asm  of  the  larynx,  and  the  reflex  excitability  of  the  larynx 
becomes  so  intense  that  spasm  is  later  precipitated  by  the  sight,  the  sound,  or 
the  mere  thought  of  water  or  the  mere  sight  or  touch  of  a  smooth  or  cold 
surface.  A  coachman  under  Watson's  observation  had  to  desist  from  sponging 
himself,  according  to  his  habit,  M'ith  cold  water,  though  he  said  he  "could  not 
think  how  he  could  be  so  silly."  Frequent  sighing  is  a  common  sign  at  the 
inception  of  the  disease. 

The  first  stage  usually  lasts  about  twenty-four  hours,  when  the  second 
stage,  the  spasmodic  or  true  hydrophobic  stage,  sets  in.  This  stage  is 
characterized  by  an  exaggeration  or  an  intensification  of  the  spasmodic  con- 
traction of  the  larynx.  Every  attempt  to  swallow  is  attended  with  frightful 
anxiety.  The  contraction  is  so  powerful  as  to  lead  to  dyspnoea,  with  maniacal 
excitement.  The  patient  may  strike  about  in  every  direction,  roll  his  head 
from  side  to  side,  while  the  mouth  opens  and  closes  convulsively,  sometimes 
with  snapping  sounds,  whereby  wounds  are  occasionally  inflicted  upon  minis- 
tering hands,  and  the  disease  has  actually  been  conveyed  in  this  way.  These 
convulsive  seizures  gave  rise  to  the  stories  that  hydr()i)hobic  patients  bite  and 
snap  like  dogs,  and  led,  through  the  fear  whicii  they  excited,  to  the  cowardly 
assassination  of  i)atients  by  shooting  them  down— a  practice  still  in  vogue  on 
the  confines  of  Austria — or  by  smotliering  them  between  feather  beds.  The 
})aroxysms  seem  all  the  more  dreadful  because  they  are  attended  with  the 
escape  of  glutinous,  foaming  saliva,  which  is  sometimes  ejected  with  great 
force  in  every  direction.  Tnsjiiration  is  also  attended  with  gaping  and  sighing 
and  various  sounds,  sometimes  simulating  the  baik  and  howl  of  dogs.     These 


494  HYDROPHOBIA, 

symptoms  occur  in  paroxysms,  in  the  intervals  between  which  the  mind  is 
clear,  though  sometimes,  in  those  of  highly  nervous  temperament,  it  may  be 
excited  to  show  more  persistent  hallucination.  The  pulse  is  quickened  and 
rendered  irregular,  but  with  all  the  struggle  there  is,  as  a  rule,  but  little  ele- 
vation of  temperature. 

The  inspiratory  spasms  and  convulsive  attacks  may  cease  entirely.  The 
patient  may  become  able  to  swallow  with  perfect  ease.  The  recovery  is  illu- 
sorv,  as  the  case  usually  suddenly  succumbs  to  heart  failure. 

The  second  stage  is  thus  characterized  by  the  severity  and  intensity  of  symp- 
toms. It  is  easy  to  be  seen  that  the  convulsions  are  in  all  cases  of  reflex  ori- 
gin, and  the  disease  is  characterized  by  extreme  hypersesthesia  of  the  medulla, 
wiience  the  convulsive  manifestations  emanate  on  the  very  slightest  outside 
irritation.  Another  distinguishing  feature  is  the  mental  anguish,  the  unspeak- 
able terror,  which  is  depicted  upon  the  face.  During  the  paroxysms  the  patient 
may  lose  his  self-control.  He  may  foam  at  the  mouth,  make  snapping  move- 
ments in  convulsions,  whereby  he  may  even  accidentally  or  apparently  pur- 
])osely  inflict  wounds  upon  attendants,  but  so  soon  as  the  paroxysm  is  over  he 
recovers  consciousness,  and  usually  apologizes  pitiably  for  his  excess.  He  may 
even  warn  his  attendants  to  subject  him  to  greater  restraint  in  protection  of 
themselves.  The  employment  of  any  forcible  measures,  however,  as  a  rule, 
aggravates  the  explosion. 

The  second  stage  usually  lasts  from  one  to  three  days,  rarely  as  long  as 
four  days.  The  patient  now  becomes  gradually  exhausted.  Paroxysms  occur, 
but  they  are  less  intense.  The  extreme  anxiety  of  mind  is  diminished  ;  there 
are  intervals  of  nearly  complete  tranquillity.  It  is  plain  to  see,  however,  that 
while  the  breathing  is  easier  and  the  explosions  less  severe,  and  while  there 
may  be  even  ability  to  swallow,  the  patient  becomes  more  and  more  prostrated 
and  reduced.  The  strong  man  is  broken.  The  heart's  action  is  weak,  the 
])ulse  flutters,  the  surface  is  covered  with  a  cold  sweat.  The  movements  of 
the  body  are  so  much  enfeebled  as  to  present  the  appearance  of  paralysis ; 
hence  this  second  stage  has  been  characterized  as  the  "stadium  paralyti- 
cum."  Death,  which  may  occur  suddenly  in  a  convulsion  or  from  as- 
j)hyxia,  usually  comes  on  quietly  from  failure  of  the  heart. 

Hydrophobia  is,  as  stated,  an  exquisitely  acute  infection.  However  long 
the  period  of  incubation,  the  whole  duration  of  the  disease  proper  is  measured 
in  a  few  days.  Of  all  cases,  82  per  cent,  perish  in  from  two  to  four  days. 
Individual  cases  may  succumb  in  two,  or  may  last  as  long  as  five  or  six, 
days. 

The  diagnosis  is  generally  easy,  and  rests  chiefly  upon  the  heightened 
reflex  of  the  medulla  as  manifested  by  S])asm  in  the  muscles  of  deglutition  and 
respiration. 

The  disease  is  differentiated  from  tetanus  by  its  much  longer  period  of  incu- 
bation. Tetanus  occurs  in  from  three  to  ten  days  after  the  wound  or  injury. 
Tetanus  usually  begins  with  trismus,  and  is  often  attended  with  opisthotonos. 
It  lacks  the  laryngeal  symptoms  and  spasms  of  hydrophobia.     It  lacks  also 


PROGNOSIS.  495 

the  psychical  exaltation  and  mental  anguish  of  hydrophobia.     Tetanus  aiay 
also  be  distinguished  by  its  special  niiero-organism. 

The  disease  is  often  distinguished  with  irreat  diflficidtv  from  the  imao;inarv 
condition  known  as  lyssophobia,  or  fear  of  hydrophobia.  These  cases  have  a 
common  origin,  though  in  the  one  case  the  wound  comes  from  a  non-affected 
animal.  It  might  be  imagined  that  lyssophobia  occurred  more  frequently  in 
nervous  subjects  or  in  women.  This  is  not  tiie  case.  The  strongest  men  have 
suffered,  and  not  infrequently  actually  succumbed  to  fright  or  fear  of  hydro- 
phobia. Some  of  these  cases  have  been  rescucxl  by  knowledge  of  the  fact  that 
the  animal  was  not  rabid  ;  hence  the  advisibility,  when  possible,  of  secluding 
the  animal,  that  the  existence  or  course  of  its  disease  may  be  observed.  The 
fact  that  the  animal  recovers  at  all  almost  necessarily  excludes  hydrophobia. 
Abundant  cases  are  recorded  where  information  of  the  recovery  of  the  animal  or 
the  sight  of  the  animal  itself  has  allayed  the  most  intense  nervous  symptoms. 

The  prognosis  is  fatal.  It  is  commonly  said  that  the  physician  who  cures 
is  death.  Bollinger  goes  so  far  as  to  say  that  the  cases  of  alleged  recovery 
may  be  invariably  found  to  be  due  to  some  other  disease  or  to  the  fact  that  the 
animal  was  not  rabid.  Yet  it  must  be  admitted  that  dogs  have  recovered  from 
the  disease.  Law  mentions  eight  such  cases,  two  of  which  were  attested  by 
successful  inoculation  of  other  animals.  The  possibility  of  spontaneous  recov- 
ery may  therefore  be  entertained  in  man.  Wounds  on  i\\Q  face  are,  as  stated, 
always  the  most  serious.  Bouley  declares  that  90  per  cent,  of  these  cases  are 
followed  by  hydrophobia,  whereas  the  mortality  from  wounds  of  the  hands  is 
63  per  cent.,  of  the  lower  extremities  28,  and  of  the  u})per  extremities  20 
per  cent.  Bites  in  the  vicinity  of  motor  nerves  are  the  most  dangerous  ;  the 
wilder  the  animal  and  the  longer  the  teeth,  the  shorter  is  the  incubation  and 
the  more  grave  the  prognosis  (Babes).  Many  cases  are  certainly  rescued  by 
prompt  treatment.  Bollinger  quotes  in  proof  of  this  the  foUow'ing  statistics 
in  France  :  Of  200  human  beings  bitten  by  rabid  animals,  134  were  cauter- 
ized. Of  these,  92 — that  is,  69  per  cent. — remained  healthy,  while  42 — that 
is,  31  per  cent. — died  of  hydrophobia.  Of  those  non-cauterized,  83  per  cent, 
succumbed  to  the  disease.  In  one  case  16  persons  and  1  ass  were  bitten  by 
the  same  animal.  The  human  beings  were  cauterized  and  rescued  without 
exception.     The  ass,  which  received  no  treatment,  died  of  the  disease. 

The  only  true  prophylaxis  is  through  the  enforced  use  of  the  muzzle, 
which  renders  all  other  prophylaxis  sn|)erHuous;  but  for  various  reasons, 
including  a  kind  of  sentimentality,  the  process  of  muzzling  has  never  been 
rigidly  enforced  outside  of  a  military  country  like  Prussia.  The  disease, 
which  was  formerly  common  in  Prussia,  was  actually  extinguished,  as  stated, 
for  nine  vears  bv  the  rijiid  enforcement  of  universal  muzzlinu.  Holland  secured 
the  same  exemption  in  the  same  way.  The  miinber  of  dogs  may  be  limited  by 
imposition  of  higher  taxation.  Every  dog  should  have  a  known  master. 
Suspected  dogs  must  be  carefully  confined  for  as  long  a  period  as  six  months. 
Dogs  imported  from  countries  of  lax  laws  in  this  regard  should  be  quaran- 
tined for  six   months.     Actually  rabid  dogs  or  other  animals  that  need  not  l)e 


496  HYDROPHOBIA. 

preserved  to  determine  the  condition  of  human  beings  or  other  animals  at- 
tacked should  be  killed  at  once.  Filing  the  teeth  or  attachment  of  blocks 
of  wood  about  the  neck,  confinement  by  chains,  attempted  prophylaxis  by 
injection  of  virus,  are  all  means  too  unreliable  for  practice. 

Treatment  consists  in  the  destruction  or  elimination  of  the  poison  in  the 
wound.  i\bsorption  should  be  first  prevented  where  practicable,  as  on  the 
extremities,  bv  a  ligature  above  the  wound.  A  piece  of  cord  or  handkerchief 
should  be  firmly  twisted  about  the  limb  with  a  piece  of  wood.  Where  it  may 
be  done  the  patient  should  withdraw  the  poison  from  the  wound  by  suction. 
With  proper  precautions  this  act  may  be  substituted  by  another  person.  The 
act  of  suction  is,  however,  dangerous  in  cases  of  carious  teeth  or  wounds  in  the 
gum,  cheek,  or  other  parts  of  the  mouth.     The  operation  may  be  performed,  j 

nevertheless,  if  the  individual  take  tlie  precaution  to  rinse  the  mouth  thor- 
ouglily  after  every  suction  with  carbolic  acid.  Hertwig  found  that  the  virus 
of  hydrophobia  applied  to  the  mucous  membrane  of  the  mouth  and  digestive 
tract  was  entirely  innocuous.  This  process,  which  has  been  resorted  to  from 
the  most  ancient  times,  has  never  yet  proven  infectious.  In  the  first  decades 
of  the  present  century  in  Lyons  certain  women,  hundsdugnerinnen,  pursued 
this  business  as  an  avocation.  They  received  ten  francs  for  the  first,  and  five 
for  each  succeeding  act.  On  the  surface  of  the  trunk  and  some  parts  of  the 
face  the  poison  may  be  exhausted  by  cups.  Immediately  after  suction  the 
wound  should  be  cauterized.  Youatt  relied  entirely  upon  such  a  superficial 
caustic  as  the  nitrate  of  silver.  As  he  was  himself  bitten  seven  times  and 
operated  on  400  persons,  only  1  of  whom  died — and  that  one,  as  he  declared, 
from  fright — this  caustic  may  be  considered  sufficiently  strong  if  applied 
immediately.  Caustic  potash  burns  deeper.  The  actual  cautery,  as  from  a 
poker,  a  nail,  the  galvano-cautery  brought  to  a  white  heat,  would  certainly 
destroy  the  poison  more  effectually.  Where  wounds  are  very  extensive  or 
numerous,  the  effect  may  be  best  accomplished  with  stronger  solutions,  1  :  500 
or  1  :  1000,  of  corrosive  sublimate.  Extensive  laceration  of  extremities  may 
require  amputation. 

Psychi(;al  treatment  is  of  supreme  importance.  Romberg  first  advised  the 
necessity  on  the  part  of  the  attendant  and  friends  "  to  preserve  a  calm  demean- 
or, to  avoid  all  allusion  to  the  previous  injury,  and  to  appear  cheerful."  To 
secure  diversion  without  effort  or  remark  is  an  essential  factor  in  the  relief  of 
suffering  at  least.  The  intense  reflex  excitability  of  the  medulla  is  best  met 
by  seclusion  in  a  quiet  and  rather  dark  room.  The  exhibition  of  cases  as  curi- 
osities or  as  objects  of  morbid  sympathy  is  a  cruelty,  if  not  a  crime.  Frequent 
warm  baths  where  at  all  permissible,  as  at  the  very  start,  tend  to  allay  exci- 
tability and  spasm.  Very  soon,  however,  resort  must  be  liad  to  anodynes  and 
anaesthetics.  Violent  cases  may  require  the  use  of  chloroform.  The  same 
ol>ject  may  be  at  first  obtained  with  chloral.  The  various  remedies  recom- 
mended as  specifics — curare.  Calabar  bean,  pilocarpine — have  proven  useless 
except  in  allaying  spasms.  The  use  of  animal  poisons  has  proven  equally 
futile.     Watson  speaks  of  cases  treated  with  the  virus  of  snake-bites.     One 


TREA  TMEXT.  497 

man  was  bitten  by  nine  vipers  without  effect.  Opium  is  the  best  shield. 
Sooner  or  later  resort  must  be  had  to  morphine,  in  the  later  course  of  the 
disease  preferably  subcutaneously,  with  a  view  to  at  least  secure  euthanasia. 
With  this  history  hitherto  it  may  be  appreciated  with  what  acclamation  was 
hailed  the  claim  by  Pasteur  of  the  discovery  of  a  means  of  preventing  the 
disease  by  the  use  of  attenuated  virus.  It  had  been  always  known  that  the 
disease  expends  its  main  force  uj)on  the  medulla.  Whatever  lesions  are 
encountered  in  the  disease  are  seen  here. 

As  soon  as  Pasteur  had  determined  that  the  virus  of  hydrophobia  comes 
to  be  located  in  the  central  nervous  system,  especially  in  the  spinal  cord,  he 
began  his  experiments  with  this  substance  to  secure  attenuated  matter.  He 
found  that  a  continued  inoculation  of  the  virus  from  rabbit  to  rabbit  increased 
its  virulence  to  such  degree  that  after  about  twenty-five  generations  he  got  a 
virus  which  showed  its  effect  after  an  incubation  of  but  eight  days.  In  twenty- 
five  generations  further  the  period  of  incubation  was  limited  to  seven  days. 
This  virus  was  taken  as  a  so-called  virus  fixe  as  a  basis  substance  for  protective 
inoculation.  Pasteur  discovered  that  desiccation  of  the  medulla  from  such  an 
animal  in  sterilized  glass  vessels  in  which  had  been  put  pieces  of  caustic  pot- 
ash brought  about  a  gradual  reduction  of  virulence.  Tiie  medulla  became  less 
and  less  poisonous.  The  drying  process  was  continued,  until  after  two  weeks' 
desiccation  it  was  entirely  innocuous.  Injections  were  now  made  with  an 
emulsion  of  the  non-virulent  medulla,  and  were  followed  by  emulsions  of 
medullar  of  increasing  virulence,  up  to  those  whicli  had  been  dried  but  one  or 
two  days.  Dogs  so  treated  were  immune  to  infection  with  fresh  hydropliobic 
matter. 

In  the  treatment  of  the  hydrophobia  of  man  Pasteur  began  with  weaker 
preparations — to  wit,  with  the  medulla  of  the  rabbit  after  fourteen  days'  desic- 
cation, and  increased  the  following  days  up  to  that  of  the  fifth  day,  whereby 
immimity  or  protection  was  secured.  The  attempt  to  use  stronger  preparations 
in  a  shorter  time  in  protection  against  the  more  dangerous  and  extensive  lace- 
ration of  wolf-bites  had  to  be  discontinued.  This  treatment  has  been  used  now 
in  thousands  of  cases,  and,  while  it  cannot  be  said  to  have  furnished  perfect 
results,  as  a  number  of  cases  thus  treated  have  nevertheless  succumbed  to  the 
disease,  it  must  be  admitted  that  the  majority  of  cases  have  been  rescued  from 
the  horrors  of  hydrophobia. 

A  better  method  is  promised  in  tlie  conclusions  of  Centanni,  \\\\o  utilized 
the  princij)le  of  antirabic  vaccination  (inoculation),  first  devised  by  an  ohi 
Italian  physician,  Eusebio  Valli,  in  the  production  of  an  innocent  virus 
obtained  by  tlie  action  of  gastric  juice  upon  tlic  cords  of  infected  rabbits. 
The  cord,  emulsified  in  peptones,  gradually  parts  with  its  vindence,  and  loses 
it  altogether  in  twenty  iiours.  Tlie  essential  substance  is  a  flocculent  deposit, 
which  may  be  preserved  for  weeks  in  glycerin  or  dried  with  sulphui-ic  acid. 
Rabbits  can   be  thoroughly  inmiunificd  with   this  material. 

The  protective  substance  is  jirepared  as  follows:  I\)ur  grammes  of  spinal 
cord  are  emulsified  with  artificial  gastric  juice  (solution  of  English  peptones) 
Vol..  I.— -.',2 


498  HYDROPHOBIA. 

for  nineteen  hours.  At  the  end  of  this  time  a  few  drops  are  aspirated  from 
the  mixture  and  injected  into  the  sheath  of  the  sciatic  nerve  of  two  rabbits. 
The  rest  of  the  emulsion  is  neutralized  with  bicarbonate  of  sodium  and  fil- 
tered. The  essential  substance  which  remains  on  the  filter  is  repeatedly 
washed  for  several  hours  Avith  distilled  water,  and  then  dried.  The  nearly 
dry  matter  is  divided  into  three  equal  parts,  two  of  which  (each  with  5  ccm. 
of  neutral  glycerin)  are  put  into  tubes  ;  hydrogen  is  introduced  into  one,  the 
air  is  exhausted  from  the  other,  and  the  two  tubes  are  united  by  fusion.  The 
third  part  is  dried  by  sulphuric  acid. 

The  glycerin  emulsion  in  the  tube  suffices,  in  five  subcutaneous  inocula- 
tions, to  render  rabbits  absolutely  immune  in  six  days  after  infection  with 
the  ordinary  virus  (strassengift),  while  one  of  the  two  non-protected  control 
animals  died  in  seventeen,  the  other  in  eighteen,  days. 

In  subsequent  experiments  made  by  Tizzoni  and  Centanni  it  was  ascer- 
tained that  this  matter  not  only  protected  against,  but  actually  cured,  the 
developed  disease  (guarire  negli  animali  la  rabbia  sviluppata).  Five  rabbits 
infected  by  injection  into  the  sheath  of  the  sciatic  nerve  with  virus,  which 
killed  control  animals  in  fifteen  to  seventeen  days,  were  inoculated  with  the 
protective  matter,  11-26  ccm.  in  doses  of  3-5  ccm.,  twice  on  the  seventh,  once 
on  the  eighth,  once  on  the  eleventh,  and  once  on  the  fourteenth  day  after 
infection.  The  injections  were  intravenous,  subcutaneous,  and  intraperitoneal. 
In  all  five  cases  the  symptoms  of  rabies  had  more  or  less  fully  developed. 
All  five  remained  without  a  sign  of  subsequent  infection,  and  the  effect  was 
the  same  in  all  three,  regardless  of  the  method  of  application  of  the  serum. 

This  discovery,  which  promises  results  of  inestimable  value,  has,  up  to  the 
period  of  the  present  writing,  not  yet  been  utilized  in  the  treatment  of  hydro- 
phobia of  man. 


TRICHINOSIS. 

By  JAMES  T.  WIIITTAKER. 


Trichinosis  is  an  acute  infection  caused  by  the  ingestion  of  the  trichina 
{dpi^,  rpiyo^^  hair)  spiralis  in  raw  or  underdone  pork, — cliaracterized  by 
gastritis  and  enteritis,  followed,  in  consequence  of  migration  of  the  parasite, 
in  the  course  of  a  week  by  pains  in  the  muscles  and  contraction  of  the  joints, 
with  cedema  of  the  eyelids  and  face,  prostration,  insomnia,  profuse  sweats,  and 
exhaustion. 

The  history  of  the  trichina  is  wholly  modern,  and  is  all  included  in  the 
present  century.  Calcified  cajjsules  were  seen  in  the  muscles  as  early  as  1821, 
when  Hilton  first  described  them  as  minute  white  masses,  which  he  regarded 
as  cysticerci.  Peacock  made  a  preparation  for  the  museum  of  Guy's  Hospital 
in  1828.  Paget,  at  that  time  a  student  at  St.  Bartholomew's,  distinctly  noticed 
them  in  the  muscles  of  man.  He  took  a  specimen  to  Owen  in  1835,  who  gave 
the  parasite  the  very  appropriate  name  it  bears.  Leidy  in  1847  discovered 
in  a  piece  of  ham  upon  his  plate  the  same  immature  nematoid,  but  neither  he 
nor  his  predecessors  appreciated  the  significance  of  its  presence.  Horbst  (1851) 
bred  muscle  trichinae  in  doo^s  bv  feeding;  them  with  the  infected  flesh  of  a  bad- 
ger.  Leuckart  (1855)  first  saw  the  escape  of  intestinal  trichinte  from  their  cap- 
sules in  the  body  of  mice.  In  the  same  year  Kiichenmeister  maintained  that 
the  trichina  was  the  larval  state  of  the  trichocephalus  disj)ar.  This  erroneous 
view  was  more  widely  disseminated  l)y  Leuckart,  who  declared  that  he  had 
bred  trichocephali  in  myriads  by  feeding  trichinous  flesh  to  hogs.  Virchow 
was  unable  to  confirm  this  conclusion,  as  he  observed  tiie  immature  trichinse 
become  in  all  cases  mature  in  the  intestine  of  \\\q.  dog.  Cases  of  muscle 
trichinae  continued  to  be  occasionally  reported  in  England  and  America, 
as  well  as  Germany,  from  this  time  on,  l)ut  the  capsules  were  still  looked 
upon  as  dissecting-room  curiosities,  spriid<ling  muscles  like  the  deposit  of 
eggs  of  insects  and  preventing  good  preparations.  Even  the  discovery  of 
young  trichinae  in  the  capsules  in  \\\(i  breeding  experiments  of  Leuckart 
and  Virchow  contrii)ute(l  in  no  way  to  dissipate  the  belief  that  these  worms 
were  innocent,  wandering  nematoids. 

The  new  era  of  definite  knowledge  began  with  the  year  1800,  and  with  the 
study  by  Zenker  of  an  individual  case,  that  of  a  servant-girl  in  the  hospital 
at  Dresden.  This  famous  first  patient  was  attacked  about  Christmas,  1859, 
with  anorexia,  insonniia,  lassitiidt!,  depression,  and  fever.  The  case  was 
regarded  as  typhoid  fever,  a  diagnosis  whicih  had  to  be  changed  with  the 
supervention  of  a  train  of  symptoms  which  could  not  be   classed   with  the 

4  9 '.I 


500  TRICHINOSIS. 

signs  of  this  disease.  By  the  end  of  a  week  the  patient  complained  of  severe 
pain  all  over  the  body,  more  particularly  in  the  muscles,  and  more  especially 
in  the  extremities.  Any  movement  of  the  body  increased  the  pain  to  such  a 
deo-ree  that  the  patient  was  compelled  to  lie  with  the  limbs  flexed  upon  the 
body.  Pneumonia  subsequently  set  in,  and  the  patient  died  at  the  end  of  a 
month  after  the  first  signs  of  disease.  A  post-mortem  examination  revealed 
trichina?  in  myriads,  all  alive  and  in  all  stages  of  development,  lying  coiled 
and  curved  and  sti-aight  in  the  sheaths  of  the  muscle-fibres  and  in  all  the 
strij)ed  muscles,  including  the  heart  itself.  It  was  subsequently  ascertained 
that  this  domestic  had  showed  signs  of  illness  shortly  after  the  ingestion  of  a 
meal  of  ham  and  sausage.  Zenker  was  fortunate  enough  to  find  some  of  the 
same  meat  and  to  discover  in  it  encysted  trichinse.  It  turned  out  also  that 
other  domestics  had  suffered,  and  that  the  butcher,  who  was  in  turn  sought 
out  by  the  indefatigable  observer,  had  been  ill  with  rheumatism,  "as  if 
paralyzed,"  ever  since  he  had  killed  the  pig.  He  was  at  the  time  of  obser- 
vation unable  to  move  his  arm,  legs,  or  neck.  He  had  never  in  his  life  been 
ill  before,  and  attributed  his  attack  to  a  bad  cold  contracted  on  the  day  of  the 
slaughter. 

Zenker  forged  the  last  link  in  the  chain  of  his  investigations  by  sending  a 
piece  of  the  muscle  of  the  girl  to  Virchow,  who  fed  a  rabbit  with  some  of  it, 
developed  in  the  animal  general  muscular  paralysis,  and  recovered  young 
trichinse  from  its  muscles.  With  this  flesh  other  rabbits  were  fed  with  the 
same  result.  Virchow,  Leuckart,  and  Zenker  then  demonstrated  the  migra- 
tion from  the  intestine  to  the  muscles,  and  two  years  later  (1852)  Friedreich 
made  the  first  diagnosis  of  the  disease  in  life  by  the  detection  of  the  parasite 
in  a  piece  of  exsected  muscle. 

Thus  in  less  than  a  year  the  clinical  history  of  the  disease  was  established 
by  a  chain  of  evidence  which  was  complete  in  every  link.  It  was  now  soon 
recognized  that  many  cases,  even  epidemics,  which  had  hitherto  been  considered 
as  irregular  or  anomalous  typhoid  or  typhus  fever,  more  especially  malignant 
rheumatism,  occasional  cases  of  poisoning,  English  sweat,  and  black  death, 
were  due  to  this  cause.  Thus  attacks  and  epidemics  at  Wurtemberg,  Breslau, 
Magdeburg,  Hamburg,  various  districts  in  France  and  Belgium,  are  recognized 
to  have  been  cases  of  unsuspected  and  unknown  trichinosis.  On  one  occasion 
nearly  the  entire  crew  of  a  merchant- vessel  sailing  from  Valparaiso  to  Ham- 
burg was  killed  by  the  ingestion  of  pork  from  a  pig  killed  on  the  sea. 

Fa(!t  is  stranger  than  fiction.  At  a  festival  at  Hcltstadt,  Prussia,  of 
which  103  persons  jiartook,  more  than  80  ])ersons  were  attacked  with  the 
disease,  and  more  than  20  died  within  a  month.  The  cause  was  subsequently 
discovered  in  some  sausage-meat  taken  from  a  sick  pig  killed  by  mistake. 
Three  or  four  days  after  a  church  celebration  in  1846  seven  of  eight  people 
were  seized  with  diarrhoea,  pain  in  the  back  of  the  neck,  and  swelling  of  the 
face.  Four  of  the  seven  died.  The  remaining  three  continued  ill  for  a  long 
time.  The  innkeeper  was  suspected  of  having  poisoned  his  guests  with  white 
wine,  and,  though  the  charge  could  not  be  proven,  the  odium  was  so  great  as 


HISTORY. 


501 


to  compel  him  to  close  out  his  business  and  leave  his  native  land.  Eighteen 
years  afterward  Langenbeck  of  Berlin,  in  exseeting  a  tumor  from  the  neck, 
discovered  in  the  platysma  niyoides  imunuerable  dead  trichinae  enclosed  in 
calcified  capsules  in  tlie  body  of  one  of  the  survivors,  and  thereby  the  his- 
tory of  the  "  poisoning "  was  made  plain. 

Trichinosis  was  diagnosticated  for  the  first  time  in  the  United  States  by 
Schnetter  of  New  York  (1864),  and  in  the  same  year  by  Voss  in  four  cases 
on  board  one  of  the  Bremen  steamers  in  the  harbor  of  New  York.  The  dis- 
ease was  first  recognized  in  England  in  Northumberland  in  1871. 

The  trichnia  spiralis  is  present  in  man  in  both  the  developed  and  unde- 
veloped states — developed,  mature  in  the  intestinal  canal ;  undeveloped,  imma- 
ture in  the  muscles.  The  trichina  also  infects  the  how,  rat,  cat,  fox,  rabbit, 
and  guinea-pig.  It  is  a  pure  parasite,  the  sole  example  among  the  entozoa, 
having  lost  all  relation  with  the  external  world. 

The  hog  is  usually  infected  from  itself.  It  was  formerly  maintained  that 
the  hog  got  the  disease  from  the  rat,  which  w^as  once  considered  the  original 
host  of  the  parasite.  Leisering  went  so  far  as  to  declare  that  "  to  exterminate 
the  rat  is  to  exterminate  trichinae."  Zenker  showed,  however,  that  rats  get 
their  infection  from  the  hog,  and  Gerlach  established  the  fact  that,  whenever 
trichina  is  found  in  the  rat,  trichinous  hogs  or  other  carnivora  are  witliin 
reach  of  the  rat.  The  hog  is  therefore  the  peculiar  and  original  bearer  of 
trichina.  In  it  the  wdiole  course  of  the  evolution  of  the  trichina  takes  place 
(Heller). 

In  the  inspection  of  meat  care  must  be  taken  to  avoid  considering  certain 
objects  found  in  the  muscle  as  encapsulated  trichina.  First,  the  so-called 
Miescherian  sacs,  sausage-shaped  psoro-sperms  which  may 
usuallv  be  distinguished  by  the  fact  that  thev  are  traversed 
with  transverse  lines  and  discharge  upon  incision  minute 
kidney-shaped  objects  (see  Figs  34  and  35)  which  may  un- 
dergo change  of  form ;  second,  certain  crystalline  objects 
found  in  the  muscles,  described  by  Virchow  as  the  guanine 
gout ;  they  may  be  distinguished  by  the  fact  that  they  dis- 
solve on  the  addition  of  hydrochloric 
acid,  to  leave  the  muscle-fibres  un- 
affected. 

About  2  per  cent,  of  swine  are 
found  to  be  affected,  and  trichinaB 
are  found  in  the  muscles  in  about 
2  per  cent,  of  cases  in  the  dissect- 
ing-room. 

Anatomy,  etc. — Tli(>  nialurc  in- 
testinal   trichina    (see    Fig.     30)     is 
round,  elongated,  white,  and,  as  its  name  inijilies,  extremely  filiform,  on  which 
account  it  is  barely  visible  to  llic  naked  eye  as  a  fine  wool   hair  or  silvery 
thread.     The   head,   formerly  regarded   as  the  tail,  is  drawn  out  almost  to 


FtG.  34. 


Fig.  35. 


Micscher's  San,  X  100 
(Lcuckart). 


End  of  Sap,  with  kidney- 
shiipcd  bodies  free  and  en- 
eldscd  (Leuc)<art). 


502 


TRICHINOSIS. 


a  line,  while  the  caudal  extremity  is  somewhat  rounded  off  and  is  not  much 
thinner  than  the  body.     The  alimentary  canal  begins  with  a  muscular  mouth, 


Fig.  37. 


Fig.  36. 


Fig.  36.— Unimpregnated  Female  Trichina  (Leuckart). 

Fig.  37.— Male  and  Female  Triehiiue,  female  discharging  young  (Heller). 

is  continued   into    an    elongated    oesophagus,   expanding    into  a  flask-shaped 
stomach,  to  be  again  continued  into  an  intestinal  canal,  which  at  its  extremity 


Fig.  38. 


Tendinous  Inscrliuii  of  Muscle,  sLowiiig  Trichina;  Ult'llerj. 


503 


504 


TRICHINOSIS. 


receives  in  the  male  the  opening  of  the  seminal  duct,  arising  from  a  single 
testicle,  a  thi(!k  cul-de-sac  which  runs  along  the  side  of  the  body.  The 
female,  J  inch  in  length  (see  Fig.  37),  is  twice  as  long  as  the  male  to  accom- 
modate the  ova  with  which  it  is  stuffed,  and  which  are  hatched  within  the 
body  and  born  alive.  The  orifice  of  the  vagina  is  situated  at  the  junction  of 
the  first  and  second  quarters  of  the  body.  Each  female  may  give  birth,  in  the 
course  of  a  month,  to  over  a  thousand  young.  The  parent  trichinse  are  short- 
lived. They  are  probably,  for  the  most  part,  digested  and  absorbed  after 
reproduction,  as  they  disappear  from  the  intestine  in  from  five  to  eight  weeks, 
and  are,  unfortunately,  not  often  to  be  fijund  in  the  stools. 

The  newborn,  immature  trichinse,  ^ot  ^^  ^  ^^'^^  ^^  length,  having  escaped 
from  the  body  of  the  parent,  penetrate  the  intestinal  wall,  probably  by  means 
of  chemical  irritation,  to  migrate,  chiefly  along  the  meshes  of  the  connective 
tissues,  to  contiguous  muscles,  more  especially  to  the  diaphragm,  abdominal, 
intercostal,  laryngeal,  cervical,  ocular,  and  proximal  muscles  of  the  extremities, 
in  which  latter  region  they  are  crowded,  as  if  arrested,  at  the  tendinous  extremi- 
ties. (See  Fig.  38.)  Here  they  continue  to  grow  for  fourteen  days  to  the  length 
of  half  a  line,  when  they  coil  up  to  assume  the  peculiar  spiral  form  (see  Figs. 
39  and  40),  disintegrating  the  muscular  tissue,  expanding  and  thickening  the 


Fig.  39. 


Fig.  40. 


Living  Embryos  (Heller). 


Encapsulated  Trichina  (Leuckart). 


sarcolemma,  and,  as  a  result  of  the  inflammatory  process  thus  produced,  lead- 
ing to  the  formation  of  a  lemon-shaped  capsule  -5-  of  a  line  in  length,  in  which 
they  lie  for  the  most  part  singly,  or  more  rarely  in  groups  of  two,  three,  or 
even  four.  Thus  they  remain  encysted  alive  for  a  year  or  more,  exception- 
ally as  long  as  twenty-five  years,  or  become  subsequently  calcified  after  cal- 
cification of  the  containing  capsule — a  jjrocess  which  begins  at  the  poles  of 
the  cyst,  but  is  not  of  necessity  fatal  to  its  contents  even  when  complete. 
(See  Figs.  41  and  42.) 

Muscular  tissues  thus  infested  when  taken  as  food  (one  ounce  containing  at 
times  fifty  to  one  hundred  thousand  parasites)  is  dissolved  in  the  process  of 
digestion,  liberating  from  their  capsules,  in  from  three  hours  to  three  days, 


SYMPTOMS. 


505 


Fig.  41. 


Fig.  42. 


Calcified  Trichina  (Leuckart). 


Calcified  Trichince,  nat- 
ural size  (Heller.) 


the  luiLscle  trichinae,  which  attain  sexual  uiaturitv  in  the  intestinal  canal   in 
five    days,  and    then    reproduce    their    species    with    the    rapidity    described. 

Trichiuaj  have  also  been  found  in  the  blood,  mesen- 
teric glands,  and  peritoneal  cavity. 

Thus  the  trichina  spiralis,  wliich  was  formerly  re- 
garded as  an  accidental  and  inno- 
cent inhabitant  of  the  muscular 
tissue,  has  been  unmasked  since 
the  first  observation  of  Zenker  in 
1860  as  one  of  the  most  widely 
disseminated  and  deadly  of  all 
known  parasites. 

Symptoms. — The  symptoms  of 
trichinosis  varv  according  to  the 
quantity  of  trichinse  ingested  and 
the  irritation  produced.  Small 
numbers  produce  no  symptoms, 
cal(;ified  remnants  having  often 
been  found  in  autopsies  with  a  history  of  absence  of  any  symptoms  in  life. 
A  certain  stage  of  development  and  capsulation  is  also  requisite  to  infection. 
Too  young  or  insufficiently  protected  trichinae  are  killed  in  the  stomach.  Cal- 
cified capsules  may  not  liberate  their  contents.  The  irritation,  with  the  con- 
.sequent  rapid  increase  of  peristalsis  in  childhood,  often  causes  the  expulsion  of 
trichinae  unliberated  from  their  capsules  in  the  stools.  The  ingestion  of  alco- 
hol in  large  quantities  with  the  meal  may  destroy  them  as  rapidly  as  they  are 
liberated. 

The  sta<re  of  invasion,  which  shows  itself  in  from  three  hours  to  three 
days  or  longer  as  successive  quantities  may  be  ingested,  is  characterized  by 
irritation  on  the  part  of  the  stomach  and  intestines — i.  e.  by  anorexia,  nausea, 
vomiting,  tenderness  to  pressure,  pain  in  the  bowels,  and  diarrhoea.  These 
symptoms  may  be  absent  altogether  or  may  vary  greatly  in  intensity,  to 
assume  at  times  such  severity  as  to  be  mistaken  for  cholera,  as  in  the  epidemic 
of  Hedersleben,  where  three  victims  died  on  the  sixth  day.  Animals  led  with 
trichinous  flesh  often  succumb  on  the  fourth  day.  The  fever,  thirst,  headache, 
and  general  prostration,  which  may  accompany  the  local  signs,  belong  equally 
to  other  causes  of  intestinal  irritation,  and  are  not  peculiar  to  trichinosis. 
Sensations  of  distress,  nausea,  or  vomiting  may  occur  within  a  few  hours, 
and  may  repeat  themselves  for  several  days.  It  is  curious  that  the  appetite 
may  be  at  one  time  keen  and  at  another  entirely  absent.  Diarrhoea  is  much 
more  common  and  persistent.  Gastric  distress  is  often  entirely  absent.  Affec- 
tion of  the  intestine  is  present  in  the  majority  of  cases. 

Characteristic  symj)toms  announce  the  advent  of  the  stage  of  migration 
and  colonization  in  the  muscles,  which  begins,  as  a  rule,  on  the  seventh  day 
with  oedema,  functional  disturbance,  and  pain  in  the  nmscles.  GCdema  siiows 
itself  first  or  is  noticed   first,  as  a  rule,  in   the  (yelids,  disappearing  in  a  few 


506  TRICHINOSIS. 

days,  and  returning  later  in  the  course  of  the  disease.  This  oedema  is  often 
coincident  with  pain,  tension,  and  restriction  of  movement  in  the  muscles  of 
the  eyes  as  evidence  of  early  invasion  of  these  muscles,  though  the  presence 
of  oedema  here  as  elsewhere,  in  the  absence  of  muscular  signs,  has  also  been 
ascribed  to  the  action  of  some  toxic  principle  acting  upon  the  vaso-motor  sys- 
tem. (Edema  of  the  face  is  often,  that  of  the  hands  and  feet  more  rarely, 
associated  with  that  of  the  eyelids.  Pronounced  oedema  of  the  skin  over  the 
affected  muscles  occurs  even  more  constantly  than  about  the  face — is  absent,  in 
fact,  in  only  10  per  cent,  of  cases.  This  cutaneous  oedema  also  disappears  for 
a  few  days,  to  return  later.  It  is  distinguished  from  the  oedema  of  heart  and 
kidney  disease  by  its  association  with  the  muscular  signs,  as  well  as  by  the 
fact  that  it  spares  the  genital  organs,  the  scrotum,  and  labia  majora. 

Muscle-symptoms  appear  on  the  ninth  or  tenth  day  as  a  rule,  delayed  at 
times  to  the  fourteenth,  varying  in  every  grade  of  intensity  from  lassitude, 
stiffness,  or  tension  to  board-like  indurations  and  most  atrocious  pains.  The 
flexors  of  the  extremities,  the  biceps  and  muscles  of  the  calf  especially,  become 
swollen,  tense,  and  tender,  the  extremities  being  held  in  semi-flexion  to  sim- 
ulate the  postures  of  acute  articular  rheumatism.  Invasion  of  the  dia})hragm, 
abdominal,  and  intercostal  muscles  gives  rise  to  dyspnoea ;  invasion  of  the 
masseters,  which  may  excite  trismus,  renders  mastication  painful  or  impossible  ; 
while  invasion  of  the  tongue  and  pharyngeal  muscles  may  restrict  or  prevent 
deglutition,  accounting  thus  for  the  rapid  emaciation.  Invasion  of  the  larynx 
is  shown  by  hoarseness  of  voice  or  aphonia  in  20  per  cent,  of  cases,  and  of  the 
0(;ular  muscles  by  fixation  of  the  eyeball,  chemosis,  and  occasionally  by  mydri- 
asis and  nystagmus.  Impairment  of  hearing  follows  invasion  of  the  stapedius 
muscle. 

Difiiculty  of  deglutition,  alteration  of  the  voice,  especially  hoarseness,  even 
aphonia,  indicate  attack  of  the  muscles  of  the  neck.  The  most  serious  results 
ensue  in  consequence  of  invasion  of  the  diaphragm  and  intercostal  muscles. 
Most  cases  of  trichinosis  suffer  occasional  attacks  of  dyspncea.  In  fact,  diffi- 
culty of  breathing  may  come  on  early  under  toxic  influence,  as  in  the  case  of 
affection  of  the  muscles  of  the  extremities.  There  is  at  this  early  period  also, 
in  the  majority  of  cases,  and  probably  for  the  same  reason,  more  or  less  bron- 
chial catarrh  ;  and  when  this  condition  persists  into  the  period  of  immigration 
catarrhal  ])neum(mia  may  result  from  insufficient  expansion  and  defective 
expectoration.  The  development  of  pneumonia  is  difficult  to  recognize  on 
account  of  the  decubitus  of  the  patient.  Patients  occasionally  succumb  to 
hypostatic  pneumonia,  unsuspected  for  the  same  reason. 

None  and  Hoeffner  observed  in  a  certain  number  of  cases  lack  of  the  tri- 
ceps and  patellar  reflex.  It  was  absent  for  some  time,  and  then  gradually 
returned.  There  was  no  case  in  which  any  increase  was  observed,  though  the 
skin  reflex  was  unchanged.  Both  the  direct  and  indirect  excitability  of  mus- 
cles under  the  galvanic  as  well  as  under  the  faradic  current  was  markedly 
reduced. 

Among  the  disturbances  of  sensation  may  be  noticed  at  times  parsesthesia, 


MORBID    ANATOMY.  507 

more  particularly  pruritus.  Ansesthesia  is  much  more  rare.  Kratz  called 
attention  to  the  violent  neuralgic  attacks  in  the  abdomen,  the  so-called  coeliac 
neuralgias,  Avhich  occur  more  esjx'cially  in  the  second  week,  and  most  fre- 
quently at  night.  They  are  marked  by  an  intense  griping  pain  at  the  pit  of 
the  stomach,  radiating  to  the  back,  attended  with  pallor,  prostration,  coldness 
of  the  extremities,  and  collapse. 

Sweating  is  another  common  symptom  of  trichinosis.  It  occurs  early, 
always  in  connection  with  the  muscular  pains,  and  is  profuse  and  distressing 
in  correspondence  with  the  severity  of  the  latter.  It  is  often  attended  with 
miliaria,  occasionally  with  herpes.  Pustular  eruptions — Friedreich  once  found 
a  free  trichina  in  a  pustule — acne,  furunculosis,  may  follow  the  disappearing 
oedema  of  the  face. 

Still  another  quite  common  as  well  as  obstinate  symptom  is  insomnia, 
which  often  rapidly  exhausts  the  patient.  With  this  exception  the  cerebrum 
shows  no  symptoms.  Though  most  cases  are  characterized  by  apathy  or 
depression,  the  brain  remains  clear  up  to  the  last  stages  of  the  severe  attacks, 
when  somnolence,  stupor,  or  delirium  may  for  a  short  time  precede  the  end. 

Fever  does  not  belong  of  necessity  to  trichinosis.  Average  cases  show 
slight  elevations  of  temperature,  which  at  times  present  the  course  of  remit- 
tent, or  more  frequently  of  typhoid,  curves.  Fever  may  be  entirely  absent 
throughout  the  history  of  the  disease.  Severe  forms  may  be  accompanied  by 
a  temperature  of  104°  F.  When  present  it  is  irregular,  and  not  infrequently 
assumes,  as  stated,  a  typhoid  form.  The  confusion  of  trichinosis  with  typhoid 
fever  was  formerly  common,  and  the  mistake  has  occurred  not  infrequently 
even  since  the  days  of  accurate  thermometric  observ^ation.  The  irregularities 
of  the  second  and  third  week  somewhat  simulate  the  amphibolic  stage  of 
typhoid  fever.  Defervescence  is  never  so  regular  or  classical  even  when  it 
occurs  at  the  time  of  the  fall   in  typhoid  fever. 

Trichinosis  develops  no  special  symptoms  in  the  genito-urinary  apparatus. 
There  is,  as  a  rule,  no  interference  with  the  course  of  pregnancy  or  of  the 
puerperium.     Trichinse  have  never  yet  been  found   in  the  foetus. 

Morbid  Anatomy. — The  most  obtrusive  condition  is  oedema,  which  shows 
itself  abdut  the  face  and  extremities  of  infected  ])aticnts  at  any  time  after 
the  fourth  week  of  the  disease.  The  contractions  which  existed  before  death 
are  continued  after  it,  especially  in  the  arms.  The  blood  is  usually  found 
fluid,  and  there  are  free  effusions  in  the  various  serous  sacs.  Hyj)er8emia  may 
be  still  present  in  the  mucous  membrane  of  the  small  intestines.  Ecchymoses 
are  not  uncommon.  Trichinaj  may  be  sometimes  discovered  in  the  intestines 
even  as  late  as  the  eighth  week  of  the  disease.  The  spleen  is  not  enlarged. 
The  liver  is  usually  fatty.  The  heart  is  often  flabby.  The  lungs  show  signs 
of  bronchial  catarrh  and  hyjmstasis. 

The  most  characteristic  changes  are  encountered  in  the  muscles.  They  are 
at  first  simply  somewhat  pale;  later  they  become  elondy,  and  still  later  streaked 
and  shrunken.  The  trichinsr  arc  found  most  abundanfly  in  the  diaphragm, 
the  intercostal   muscles,  and  the  muscles  of  the  neck.      In  the  extremities  the 


508  TRICHINOSIS. 

body  of  the  muscle  is  frequently  free,  and  the  trichinae  are  crowded,  as  stated, 
about  the  tendons.  Under  the  microscope  it  is  seen  that  the  muscular  tissue 
has  lost  its  strise.  Nuclei  increase  in  number  and  size.  Spindle-shaped  con- 
nective-tissue cells  develop  in  the  intermuscular  connective  tissue.  The  lesion 
affects  the  muscular  structure  itself,  the  protoplasm.  The  sarcolemma  thickens 
ai)out  the  trichina  to  constitute  the  capsule.  The  muscular  tissue  subsequently 
suffers  waxy  degeneration. 

Post-mortem  examination  generally  shows  hyperemia  of  the  brain  and  its 
membranes,  enlargement  of  the  heart,  hypertrophy  of  the  walls  of  the  left 
ventricle,  fresh  pleuritic  effusions,  hyperemia  of  the  mucous  membrane  of  the 
bronchi  and  of  the  whole  alimentary  canal,  migrating  trichinse  in  all  the 
muscles. 

Duration. — The  disease  lasts  from  two  weeks  in  the  lightest  cases  to  eight 
weeks  in  pronounced  cases,  and  with  sequelae  for  the  greater  part  of  a  year  in 
the  severest  forms.  Kunze  heard  complaints  of  rheumatic  pains  in  bad  weather 
four  years  after  the  Hedersleben  epidemic,  and  Kratz  found  weakness  of  the 
muscles  in  one  case  eight  years  after  the  attack. 

It  is  a  recognized  fact  that  tolerance  to  trichinse  varies  in  different  indi- 
viduals. Children,  as  stated,  void  them  readily,  on  account  of  the  increased 
peristalsis  of  the  alimentary  canal  in  childhood.  Old  people  are  less  readily 
affected.  Certain  numbers  may  be  tolerated  with  impunity  in  adults,  but  the 
continued  ingestion  of  infected  meat  may  introduce  amounts  in  excess  of  this 
tolerance,  when  gastro-intestinal  signs  may  more  or  less  suddenly  supervene. 
Where  small  quantities  have  been  introduced,  or  where  the  mass  of  the 
trichinse  has  been  voided,  gastro-intestinal  signs  may  be  entirely  absent 
and  the  subsequent  stage  of  migration  may  be  but  little  marked.  The 
existence  of  the  parasite  may  then  be  recognized  or  suspected  to  account  lor 
long-continued,  persistent  muscular  pains  in  the  remoter  history  of  the  indi- 
vidual. The  exact  duration  of  the  disease  may  therefore  not  be  determined. 
Usually  the  lightest  cases  terminate  in  a  few  weeks,  while  the  gravest  extend 
over  many  months ;  but  the  very  lightest  so-called  ambulatory  cases  may 
suffer  pains  for  months  or  years,  and  the  cases  which  show  the  sharpest  signs 
of  invasion  may  escape  with  the  mildest  signs  connected  with  colonization.  It 
may  be  said  that  the  average  duration  of  the  disease  ranges  from  three  weeks 
to  three  months. 

The  diag-nosis  is  illuminated  often  by  the  fact  that  others  are  simulta- 
neously affected  and  by  the  inspection  of  suspected  pork,  possibly  by  the 
detection  of  mature  or  encapsulated  trichinse,  more  especially  after  a  brisk 
cathartic,  in  the  mucus,  but  never  in  the  fluid  contents  of  the  voided  stools  ; 
positively  by  the  discovery  of  immature  trichinse  in  the  muscles  extracted, 
])reforably  after  linear  incision  under  antisepsis,  from  the  deltoid  or  lower  part 
of  the  bice]is  muscles — for  the  most  part  an  unnecessary  procedure.  A  his- 
tory of  gastro-intestinal  irritation,  followed  by  constipation,  oedema  of  the 
ftice  on  the  eighth  day,  and  muscle-signs  by  the  tenth  day,  with  sweating, 
insomnia,  headache,  thirst,  and  fever,  sufficiently  characterizes  the  disease. 


DIA  GXOSIS.  509 

The  diagnosis  is  assisted,  as  stated,  by  the  fact  that  the  trichinosis  attacks 
not  one,  but  a  number  of  individuals :  at  the  same  time  it  may  be  helped  by 
the  known  habits  of  individuals  with  regaixl  to  the  character  of  food  and  its 
preparation.  The  distress  of  the  stomach,  more  especially  the  diarrluTca  which 
follows  the  ingestion  of  pork  in  the  course  of  a  few  hours  or  a  few  days,  next 
the  tenderness  of  so  many  muscles,  especially  at  the  extremities,  then  the 
oedema  of  the  eyelids  and  face,  later  the  pain  in  the  muscles  and  contraction 
of  joints,  serve  to  distinguish  the  disease. 

The  most  valuable  of  all  the  early  signs  of  trichinosis  is  oedema,  because 
it  is  so  rarely  absent  or,  as  Heller  says,  so  insignificant  and  transitory  as  to  be 
overlooked.  Usually  it  shows  itself  first,  as  stated,  in  the  eyelids  and  face  as 
early  as  the  seventh  day  of  the  disease.  In  the  extremities  it  occurs  later,  not 
before  the  ninth  day.  With  that  of  the  eyelids  it  disappears  to  return  later, 
more  pronounced  than  ever.  It  cannot  be  attributed  to  occlusion  of  vessels, 
but  is  probably  due,  as  Friedreich  claimed,  to  the  action  of  a  toxine  on  the 
vaso-motor  nervous  system. 

(Edema  about  the  eyelids  and  face,  the  result  of  local  disease,  as  from 
thrombus  of  the  orbital  veins,  compression  of  the  cavernous  sinus,  is  very  rare, 
and  is  of  course  unpreceded  by  gastro-intestinal  irritation  and  unattended  with 
pains  in  the  muscles,  sweatings,  etc.  The  absence  of  any  disease  of  the 
internal  organs  sufficient  to  account  for  the  dyspnoea,  hoarseness,  insomnia, 
oedema,  sweats,  and  pains  finally  leads  to  the  recognition  of  the  disease  even 
when  its  nature  is  entirely  unsuspecteJ  at  first. 

Cholera  is  eliminated  by  the  profuse  sweat  and  oedema  which  belong  to 
trichinosis.  The  cramps  of  cholera  may,  like  trichinosis,  attack  the  muscles 
of  the  abdomen  and  extremities,  but  they  do  not  attack  the  diaphragm  or 
intercostal  muscles  and  muscles  of  the  neck. 

Articular  rheumatism,  which  has  pain  and  sweating  in  common  with  trich- 
inosis, is  distinguished  by  the  affection  of  the  joints  proper,  more  especially  of 
the  smaller  joints,  by  the  absence  of  gastro-intestinal  irritation,  dyspnoea, 
insomnia,  and  affection  of  the  muscles  of  the  jaws  and  eyes. 

Muscular  rheumatism  selects  by  preference  other  muscles  than  those  affected 
in  trichinosis,  and  is  unattended  with  gastro-intestinal  irritation,  oedema, 
fever,  and  sweats.  Yet  Grawitz,  Virchow's  assistant,  declares  that  trichinae 
were  found,  on  auto})sy,  in  one-third  of  the  cases  of  so-called  muscular 
rheumatism. 

Typhoid  fever  is  differentiated  by  its  mental  disturbance,  characteristic 
temperature  curve,  diarrhoea  generally  throughout  the  whole  disease,  meteor- 
ism,  and  is  not  attended  with  oedema,  asthma,  and  muscular  signs. 

Meningitis  shows  herpes  as  a  rule,  hypersesthesia,  opisthotonos,  a  contracted 
abdomen,  and  has  a  different  history. 

Finally,  polymyositis,  which  shows  pain  in  the  muscles,  tension,  deformity, 
prostration,  oedema,  sweats,  and  insomnia— in  short,  most  of  the  signs  of 
trichinosis — is  distinguished  by  isolated  attacks — /.  e.  of  individuals — by  the 
absence  of  history  and    gastro-intestinal    signs,    preference    of  the    extensor 


510  TRICHIXOSIS. 

muscles,  and    exemption    of  the  diaphragm,  larynx,  tongue,   and    pharynx. 
Excised    portions  of  muscle    show    hyaline    or    waxy   degeneration,   but    no 

trichinae. 

Trichinosis  is  always  a  serious  disease,  and  the  prognosis  in  apparently 
the  mildest  cases  must  be  stated  with  reserve;  for  the  mildest  invasions  are 
sometimes  followed  by  the  gravest  symptoms  in  the  later  course  of  the  disease. 
The  mortality  rests  largely  upon  the  amount  of  meat  ingested,  but  depends 
also  upon  the  degree  of  heat  to  which  it  has  been  subjected.  In  this  regard 
there  is  a  great  diiference  between  the  outside  and  inside  of  a  large  piece  of 
meat.  Most  cases  of  infection  occur,  however,  after  the  ingestion  of  raw  or 
underdone  sausage  and  ham.  Sausage  too  quickly  taken  from  the  fire,  and 
uncooked  in  its  interior,  is  actually  the  most  common  mode  of  conveyance 
of  the  disease.  The  fact  that  the  infected  may  be  often  mixed  with  sound 
meat  explains  the  difference  in  intensity  of  symptoms  in  different  individuals 
partaking  of  the  same  quantities  of  meat  at  the  same  meal.  Children  almost 
never  succumb,  because  most  of  the  trichinae  are  ejected  by  diarrhoea.  Patients 
who  survive  the  eighth  week  generally  recover.  Severe  myositis  or  dyspnoea, 
profound  prostration,  and  nervous  symptoms  aggravate  the  prognosis.  Recov- 
ery is,  as  a  rule,  much  more  tedious  and  protracted  than  after  other  acute  infec- 
tions of  corresponding  severity.  The  mortality  ranges  from  1  to  70,  averaging 
30,  per  cent.  Death  occurs  usually  from  exhaustion  or  blood-poisoning  in 
from  four  to  six  weeks — exceptionally  earlier  from  gastro-intestinal  irritation, 
and  later  from  hypostatic  pneumonia  and  marasmus. 

In  a  recent  epidemic  in  Saxony,  235  cases  in  thirteen  places  showed  a  mor- 
tality of  14|  per  cent.,  while  the  general  mortality  in  that  country  for  the  pre- 
vious five  years  was  but  1.06  per  cent.  In  this  latest  reported  epidemic  the 
first  symptoms  appeared  from  the  sixth  to  the  tenth  day  after  the  ingestion  of 
insufficiently  smoked  sausages.  The  symptoms  were  anorexia  and  nausea, 
pain  in  the  stomach,  severe  diarrhoea  persisting  for  several  days  ;  thereupon 
contractions  and  pains  in  the  joints,  pains  in  the  muscles,  swelling  of  the  legs, 
more  rarely  of  the  arms,  hands,  and  neck  ;  oedema  of  the  eyelids  was  always 
present.  There  was  little  bronchial  catarrh  and  less  pneumonia.  The  heart 
was  irregular  from  the  start.  Death  followed  in  from  the  second  to  the  tenth 
week,  most  frequently  at  the  third  and  fourth  week,  from  dyspnoea  and  heart 
failure ;  in  the  more  protracted  cases  from  chronic  marasmus. 

Prophylaxis. — Naked-eye  inspection  of  meat  does  not  disclose  the  trichina 
spiralis  except  in  cases  of  calcification,  and  calcification  is  not  necessarily  fatal 
to  the  trichinae.  Putrefaction  does  not  destroy  them.  Copious  libations  of 
alcohol  with  meals  is  a  preventive  as  unreliable  as  unadvisable.  Smoking  and 
])ickling,  as  ordinarily  practised,  kill  only  the  surface  trichinae.  A  tempera- 
ture of  160°  F.  is  fatal  to  the  trichina,  so  that  thorough  cooking  of  meat 
offers  a  sure  prevention  of  infection.  A  long  subjection  to  high  temperature 
is  requisite  to  secure  penetration  to  the  interior  of  a  large  mass  of  meat  of  the 
necessary  grade  of  heat. 

Treatment. — Successful  therapy  depends  upon  an  early  diagnosis,  which  is 


TUEA  TMEXT.  5 1 1 

often  unattainable.  A  brisk  cathartic,  calomel,  gr  x-xx,  castor-oil  f5j,  or 
infusion  of  senna,  followed  by  irrigation  of  the  colon,  offers  a  hope  of  dis- 
charging many  of  the  Avorms  before  they  have  been  liberated  from  their  cap- 
sules; and,  inasmuch  as  Kratz  and  Cohnheim  found  trichinae  in  the  stools  as 
late  as  the  twelfth  week,  it  may  be  said  that  it  is  never  too  earlv  or  too  late, 
for  purposes  either  of  diagnosis  or  of  therapy,  to  give  this  method  trial. 
Recently  liberated  trichinae  may  be  benumbed  and  more  readily  discharged  by 
the  administration  of  thymol,  3J-iss,  divided  into  two  or  three  doses  (capsules), 
or  extract  of  male  fern,  3J-iv.  After  colonization  in  the  muscles  the  treat- 
ment becomes  purely  symptomatic.  The  ho])e  of  radical  extermination  by 
rapidly  diifnsible  agents,  picric  acid  and  benzine,  or  water-extracting  agents, 
glycerin  and  alcoliol,  has  proven  illusory.  Applications  of  hot  water,  salicylic 
acid,  gr.  vij,  salicin  or  salol,  gr.  x,  more  especially  phenacetin,  gr.  x,  or  anti- 
pyrine,  gr.  v,  every  hour,  may  be  tried  in  relief  of  pain  not  so  great  as  to  indi- 
cate morphine,  which  becomes  a  necessity  in  severer  cases.  Sodium  bromide, 
gr.  xl,  phenacetin,  gr.  x,  chloral,  gr.  xv,  may  suffice  to  secure  sleep,  which  is, 
however,  in  bad  cases  forced  only  by  morpliine.  As  the  safety  of  the  patient 
depends  upon  speedy  encystment  of  the  trichinae,  a  process  which  is  hindered 
by  motion  of  every  kind,  repose  and  quiet  as  absolute  as  possible  should  be 
enjoined  and  secured.  The  strength  is  to  be  sustained  by  alcohol  and  food 
until  the  force  of  the  disease  is  spent. 


GLANDERS. 

By  JAMES  T.  WHITTAKER. 


Glanders  (from  Lat,  gla7is,  gland);  Farcy  (from  far  do,  to  stuff) ;  Greek, 
fiaXcz ,  Lat.,  Malleus,  Maliasraus;  Ger.,  Rotz,  Wurm  ;  Fr.,  Morve, — an  infec- 
tion, acute  and  chronic,  of  the  horse  and  allied  solipeds,  ass  and  bastards ; 
communicable  by  inoculation  to  many  domesticated  animals  (but  not  to  cattle) 
and  to  man ;  produced  by  a  specific  bacillus ;  characterized  by  the  formation 
of  nodules  (granulomata)  and  ulcers  in  the  mucous  membrane  of  the  nose, 
with  discharge  of  foetid  pus  as  from  glands,  whence  glanders,  and  also  by 
deposits  in  the  skin  and  subcutaneous  lymph-structures,  whence  farcy  ;  and 
subsequent  general  infection. 

Apsyrtus,  a  veterinary  surgeon  in  the  army  of  Constantine  the  Great,  is 
credited  with  hashing  made  the  first  mention  of  glanders  under  the  name  malls, 
a  term  which  included,  however,  many  other  maladies.  Vegetius  also  spoke 
of  it,  and  Aristotle  described  it  in  asses.  The  disease  had  in  former  times  a 
much  more  intense  interest  in  that  to  it  at  various  periods  was  credited  the 
origin  of  syphilis,  tuberculosis,  scrofula,  diphtheria,  and  pyaemia.  The  chief 
interest  of  glanders  at  the  present  day  is  in  connection  with  diseases  of  the 
horse. 

The  first  case  of  glanders  in  man  was  recognized  by  Lorin,  a  French  mili- 
tary surgeon,  in  1812.  The  case  was  that  of  a  veterinary  surgeon  who  had  per- 
formed an  operation  upon  a  diseased  horse,  and  had  become  affected  with  the 
disease  in  the  form  of  tumors  on  the  fingers  of  both  hands.  The  tumors  in 
this  case  were  extirpated  and  the  man  recovered  in  fourteen  days.  Schilling 
of  Berlin  and  Mtiscroft  of  England  recorded  accurately-studied  cases  in  1821. 
Rayer  published  the  first  monograph  in  1837.  Virchow  contributed  exhaust- 
ively to  the  pathology  of  the  disease  in  1855-63. 

The  question  as  to  the  possibility  of  spontaneous  origin  was  definitely 
denied  with  the  discovery  by  Loffler  and  Schlitz  (1882)  of  a  specific  bacillus, 
the  bacillus  mallei,  which  these  observers  isolated,  cultivated,  and  inoculated 
to  reproduce  the  disease  in  the  horse. 

The  bacilli  of  glanders  much  resemble  in  form  and  size  those  of  tuberculo- 
sis and  lei)rosy,  though  shorter  and  more  slender  than  either.  They  are  immo- 
bile, maintain  their  virulence  when  desiccated  for  three  months,  and  are  readily 
colored  with  alkaline  aniline  dyes.  They  fi)rm  a  characteristic  colony  on  the 
surface  of  the  potato  as  a  delicate  yellowish  transparent  coat,  like  a  thin  layer 
of  honey,  as  early  as  the  second  day.     Acting  upon  the  methods  of  Koch  with 

512 


SYJIPTOMA  TOL  OGY.  513 

tuberculin,  Kalning  (Dorpat,  1891)  succeeded  in  extracting  from  cultures  a 
product  which  he  proposed  to  use  in  prevention  and  treatment.  Unfortunate- 
ly, Kalning  fell  a  victim  to  inoculation  with  the  disease,  but  his  studies  were 
immediately  taken  up  by  Preusse  (Danzig)  and  Pearson  (Berlin),  who  also  suc- 
ceeded in  extracting  a  dark-yellow,  rather  opaque,  oily  fluid  of  peculiar  odor 
and  neutral  reaction,  which  they  called  mallein  (ghmders  lymph),  and  with 
which  they  obtained  characteristic  reactions  in  horses  affected  with  the  disease. 

The  original  seat  of  the  disease  in  the  majority  of  cases  is  the  nasal  mucous 
membi'ane,  whence  it  may  be  disseminated  through  the  body,  to  show  itself 
more  especially  in  the  skin.  The  disease  may  be  always  recognized  unmis- 
takably by  the  examination  of  tissue  exsected  from  the  masses  in  the  nose  or 
in  the  skin.  The  bacilli  are  not  readily  recognized  in  fluid  secretions,  as  they 
are  easily  destroyed  by  other  bacteria.  Field-mice  cannot  be  used  for  the  phys- 
iological test,  as  they  are  so  exquisitely  susceptible  to  the  bacteria  of  septicaemia. 
The  guinea-pig  is  to  be  preferred,  as  offering  a  much  more  exclusive  soil. 

The  disease  is  disseminated  through  the  lymph-vessels  and  also  through  the 
blood-vessels,  and  is  communicated  to  man  either  through  a  broken  integument, 
especially  in  the  nose,  during  the  process  of  currying  or  feeding,  or  through 
other  contact  with  diseased  horses,  as  in  slaughtering,  skinning,  and  tanning. 
It  is  sometimes,  but  much  moi'e  rarely,  conveyed  by  the  ingestion  of  infected 
meat,  a  mode  of  infection  more  common  in  animals  fed  upon  horseflesh,  as  in 
menageries.  The  most  unsuspected  and  unavoidable  infection  (foi'tunately,  of 
most  rare  occurrence)  is  that  which  occurs  in  inhaling  into  the  nose  or  open 
mouth  the  discharges  from  a  horse's  nose  or  mouth,  as  after  the  act  of  sneez- 
ing, snorting,  coughing,  etc.  Exceptional  cases  have  been  recorded  from 
drinking  from  the  same  pail  used  in  watering  horses  or  from  the  common 
use  of  a  handkerchief  The  bacillus  may  also  be  lifted  into  the  air  and  dis- 
seminated in  the  vicinity  of  the  animal,  especially  in  close  apartments,  stables, 
etc.,  whence  it  may  be  inhaled  into  the  respiratory  tract  of  man.  The  disease 
has  attacked  and  exterminated  an  entire  family,  man,  wife,  and  four  children, 
from  the  use  of  the  same  dish.  Glanders  occurs  in  the  great  majority  of  cases 
among  hostlers,  coachmen,  drivers,  stock-farmers,  veterinary  surgeons,  butchers 
— that  is,  individuals  who  come  in  closest  contact  with  the  horse — and  is  of 
course  much  more  common  in  the  male  sex.  Bollinger  found  but  6  females 
in  120  cases,  and  then  in  the  case  of  women  compelled  to  substitute  men  in 
the  care  of  horses.  For  the  same  reason  children  are  almost  exempt  from  the 
disease. 

Symptomatology. — Man  is  nnich  less  susceptible  to  glanders  than  the 
soliped.  The  period  of  incubation  after  inoculation  or  inspiration  varies 
from  three  to  five  davs  ;  it  may  extend  to  three  weeks.  The  disease  mani- 
fests  itself  at  the  point  of  inocidation  with  redness,  swelling,  and  pain,  with 
peedy  affection  of  the  neighboring  lyuiphatics.  Constitutional  signs  occur 
in  the  course  of  a  few  days.  They  may  even  ])recede  apjiarent  <;hanges  in 
the  wound.  Chilly  sensations  with  fever  are  attended  with  headache  and 
prostration.       Vague  rhcuinatic   pains,    more  especially   in   the   neighborhood 

Vol..  I.— 33 


s 


514 


GLAKDEBS. 


of  the  joints,  with  local  symptoms  in  the  skin,  may  more  distinctly  announce 
the  infection.  Where  or  while  the  local  symptoms  or  the  cutaneous  signs  are 
still  absent  the  disease  simulates  typhoid  fever,  for  which  it  has  often  been 
mistaken.  The  character  of  the  disease  is,  however,  soon  made  manifest  by 
the  appearance  of  hard  red  nodules,  varying  in  size  from  a  pea  to  a  walnut, 
much  resembling  tiie  eruption  of  small-pox.  These  nodules  soon  show  soft- 
ening of  the  centre,  and  become  converted  into  pustules  which  burst,  to  give 
vent  to  thick,  foetid  pus.  The  nodules  may  increase  to  such  magnitude  as  to 
form  tumors,  the  so-called  farcy- buds,  or  in  the  process  of  suppuration  consti- 
tute abscesses,  the  rupture  of  which  leaves  ulcers.  These  ulcers  may  destroy 
tissue  to  such  depth  as  to  expose  the  tendons  and  bones.  The  process  may 
extend  rapidly  in  twenty-four  to  forty-eight  hours,  or  more  slowly  to  persist 
for  three  or  four  weeks. 

It  is  a  fact,  to  be  explained  perhaps  by  the  role  of  the  nose  in  respiration, 
that  while  the  manifestations  in  the  skin  are  much  less  frequent  and  severe  in 
the  horse,  symptoms  on  the  part  of  the  nose  assuming  in  this  animal  so  much 
greater  prominence,  the  converse  is  true  of  man.  Glanders  in  the  nose  is  less 
frequent  and  severe  in  man  than  in  the  horse.  Hauff  declares  that  in  more 
than  half  the  cases  in  man  the  nose  is  not  at  all  affected.  Occurring  in  man, 
it  shows  the  same  symptoms  as  in  the  horse.  The  secretions,  which  may  come 
only  from  the  affected  side,  soon  become  changed,  and  the  discharge  from  the 
nose  shows  the  same  thick,  purulent,  foetid  matter  as  in  the  case  of  the  horse. 
There  may  be  usually  seen  at  a  glance  on  inspection  such  swelling  and  redness 
of  the  nose  and  face  as  at  times  to  simulate  erysipelas.  Sometimes  tubercles 
may  be  discovered  upon  the  alae  of  the  nose.  (See  Fig.  43),     As  in  the  horse, 

Fig.  43. 


Hainan  Glanders  (Pepper). 


the  affection  of  the  nose  may  show  itself  later  in  the  course  of  the  disease, 
often  in  the  second  or  third  week.  The  raucous  membrane  of  the  eyes,  mouth, 
fauces,  and  of  the  whole  respiratory  tract  may  subsequently  become  involved. 
The  appearance  of  the  membrane,  with  the  tendency  to  haemorrhage,  foetor  oris, 
and  dysphagia,  may  much  resemble  scurvy.     There  may  be  always  observed 


SYMPTOMATOLOGY.  515 

in  these  cases  the  same  involvement  of  the  i> lands.     The  submaxillarv  and 
sublingual  glands  may  suppurate  to  discharge  externally. 

Affection  of  the  bronchial  nuicous  membrane  is  evidenced  by  harassing 
cough,  with  ihe  profuse  expectoration  of  the  same  foetid  matter  and  the  subse- 
quent development  of  dyspnoea.  Fever  may  be  entirely  absent,  or  may,  in  an 
individual  case,  assume  prominence,  with  a  temperature  of  106°  F.,  and  a 
feeble,  irregular  pulse,  like  that  of  pysemia. 

The  chronic  distinguishes  itself  from  the  acute  form  by  its  less  intense 
manifestations  and  more  protracted  course.  The  affection  of  the  nose,  when 
present,  does  not  vary  in  any  essential  from  that  already  described.  It  is, 
however,  less  frequently  present  in  man  than  is  the  acute  form  of  the  disease. 
There  is  the  same  purident  discharge  with  its  excessive  fcetor,  the  same  swell- 
imr  of  the  whole  structure,  while  the  nares  are  blocked  with  offensive  crusts. 
Peculiar  repulsiveness  is  added  to  individual  cases  by  gangrenous  changes 
which  may  occur  at  the  root  of  the  nose. 

The  manifestations  in  the  skin  are  much  more  common,  and  upon  these  the 
diagnosis  is  for  the  most  part  established.  Nodular  masses  may  form  any- 
where over  the  body,  more  especially  upon  the  extremities,  to  discharge  san- 
guineous serum  and  pus.  Sometimes  the  affection  is  more  superficial,  and 
shows  itself  in  the  form  of  blebs,  which  may,  as  stated,  closely  simulate  small- 
])ox,  chicken-pox,  or  pemphigus.  These  blebs  or  bullae  later  show,  however, 
])urulent  contents  or  break  to  leave  sluggish,  indolent  ulcers  and  erysipelatous 
appearances,  which  are  liable  to  occur  in  the  course  of  the  disease,  not  only  on 
the  surface  of  the  body,  but  also  about  the  face.  Lymphangitis  and  lymph- 
adenitis develop  as  in  the  case  of  acute  glanders.  The  whole  disease  runs  a 
much  more  sluggish  and  less  intense  course.  The  fever  is  even  more  irregular 
than  in  cases  of  acute  glanders.  It  is  sometimes  absent  for  a  certain  period, 
but  shows  itself  sooner  or  later,  if  only  in  consequence  of  the  extensive  sup- 
purative process,  as  a  pyaemia.  Profuse  sweats  with  colliquative  diarrhoea,  as 
a  rule,  soon  exhaust  the  patient.  It  may  be  said  that  the  picture  of  glanders, 
like  that  of  anthrax,  varies  according  as  the  disease  shows  itself  in  local  signs 
at  its  point  of  entry,  or  constitutionally  as  the  result  of  absorption  and  dis- 
semination in  the  various  tissues  and  organs.  In  the  first  case  the  disease 
shows  itself  in  the  skin  or  the  mucous  membrane  in  the  form,  as  stated,  of 
nodules,  which  undergo  suppuration  with  lymphadenitis,  erysipelatous  and 
])hlegmonous  inflammation.  The  discharge  from  the  nose,  with  its  character- 
istic ha&morrhagic  appearance  and  foetid  odor,  is  often  the  first  sign  to  excite 
suspicions  of  the  nature  of  the  disease.  Violent  ]iain  in  the  frontal  region 
indicates  extension  to  the  frontal  sinuses.  Chills  and  fever  announce  absorp- 
tion of  the  bacilli  into  the  blood.  The  |)rof()und  jirostration,  more  especially 
the  depression  of  the  sensorium,  leads  often  to  a  diagnosis  of  typhoid  fever, 
small-pox,  or  i)yicmia,  but  the  localizations  in  the  skin,  the  abscesses,  and 
idcerative  processes  in  the  mucosae  declare  the  character  of  the  disease.  The 
various  complications  of  pyaemia  may  subsequently  ensue:  arthritis,  serous  or 
suppurative  inflammations  of  the  various  serous  membranes,  with  exudations, 


516  GLANDERS. 

suppurating  nodules,  and  masses  in  the  muscles  and  bones,  followed  by  exten- 
sive destruction  of  muscle  and  necrosis  of  bone,  with  deep  erosions  in  the 
mucosse    and    subcutaneous    tissues,    are    common    phenomena   of    marked 

cases. 

These  various  complications  may  follow  each  other  rapidly  in  acute  cases. 
The  blood  is  quickly  poisoned,  and  the  patient  succumbs  in  the  course  of  a 
week,  in  the  more  subacute  cases  in  two  to  four  weeks,  with  delirium  and 
coma.  The  disease  is  much  more  protracted  in  chronic  cases.  It  may  last  for 
several  weeks,  months,  even  years,  and  finally  cause  death  by  marasmus. 
There  is  during  all  this  time  constant  liability  to  the  development  of  the  acute 
form  with  its  more  rapidly  fatal  consequences. 

Morbid  Anatomy. — The  surface  of  the  body  presents  the  appearance  of  a 
case  of  pysemia  in  that  various  eruptions,  pustules,  abscesses,  and  ulcers  show 
themselves  upon  the  surface,  especially  on  the  face  and  extremities.  The  pre- 
dominance of  blood  in  the  contents  of  the  pustules  or  nodules  distinguishes 
the  lesions  of  glanders  from  those  of  a  simple  pyaemia.  The  appearance  of 
the  face,  the  condition  of  the  nasal  and  frontal  bones,  may  at  once  reveal  the 
nature  of  the  disease.  Extensive  erosions,  the  result  of  masses  of  cicatricial 
tissue  in  the  nasal  mucous  membrane,  with  necrosis  of  bone,  are  further  signs 
of  local  lesion.  Sometimes  the  septum  nasi,  vomer,  the  bones  of  the  palate 
are  broken  down  and  disintegrated  as  in  the  case  of  the  horse.  Nodules  may 
also  be  found  in  the  respiratory  tract,  in  the  lungs,  and  in  almost  any  of  the 
internal  organs,  the  brain,  liver,  spleen,  and  kidneys.  The  skin  shows  the 
farcy-buds,  the  pustules,  and  abscesses.  Lymph-vessels  and  glands  in  the 
vicinity  of  these  nodules  show  signs  of  infection.  Erysipelatous  and  phleg- 
monous inflammations  may  be  seen  upon  the  surface  and  in  the  various  mem- 
branes. Serous  and  purulent  effusions  may  be  found  in  the  joints  and  serous 
cavities,  where  also  bloody  effusions  are  not  uncommon. 

The  diagnosis  is  made  to  rest  upon  the  nature  of  the  avocation  and  the 
possibility  of  exposure.  It  is  further  determined  by  the  two  signs  which  have 
given  names  to  the  disease — to  wit,  the  glanders,  which  finds  its  analogue  in 
man  in  the  term  ozaena.  It  is  to  be  remembered,  however,  that  ozeena  applies 
also  to  foetid  discharges  from  the  nose  from  various  other  causes,  notably  from 
syphilis.  The  second  factor  is  the  farcy,  the  nodular  eruptions,  abscesses,  and 
ulcers  found  in  the  skin.  The  disease  is  recognized  in  its  constitutional  form 
by  the  signs  of  pyaemia — that  is,  by  the  chills,  fever,  and  sweats,  hebetude, 
delirium,  and  coma,  together  with  the  various  metastatic  depots. 

Syphilis  may  be  separated  in  a  doubtful  case,  ex  juvantibus,  as  iodine  and 
mercury  have  no  effect  upon  glanders. 

Tuberculosis  shows,  as  a  rule,  predominating  signs  on  the  part  of  the  lungs, 
and  while  it  may  affect  the  bones,  as  in  a  case  of  glanders,  tuberculosis  dis- 
tinguishes itself  by  sparing  the  nose  and  skin,  organs  of  selection  in  glanders. 
Small-j)ox  is  more  uniform  in  its  eruption.  The  pustules  of  glanders  appear 
in  successive  crops  and  rapidly  ulcerate  (Livcing).  Pyaemia  usually  results 
from  a  single  centre  or  depot,  which  may  be  recognized  or  discovered.     Cryp- 


PROGNOSLS.— PROPHYLAXIS.  51  7 

togenetic  cases  may  be  distinguished  at  times  only  by  the  discovery  of  the 
specific  micro-organism  of  glanders. 

The  diagnosis  of  glanders  really  rests  absolutely  upon  the  recognition  of 
the  bacillus  mallei.  Travers,  long  before  the  discovery  of  the  specific  micro- 
organism, established  the  diagnosis  in  doubtful  cases  by  inoculation  of  goats 
and  rabbits  with  matter  discharged  from  some  of  the  ulcers.  Bollinofer  recoff- 
nized  the  disease  in  the  same  way  by  the  inoculation  of  a  horse.  The  inocu- 
lated animals  showed  the  special  lesions  and  succumbed  in  the  course  of  two 
or  three  months.  Cornil  succeeded  in  inoculating  two  of  fifteen  guinea- 
pigs  by  rubbing  cultures  into  the  intact  skin.  Washbourne  and  Schwartz- 
necker  established  a  diagnosis  of  human  glanders  by  the  isolation  of  the 
micro-organism,  its  cultivation,  and  the  inoculation  of  animals.  Jackowski 
called  attention  to  the  affection  of  the  testicle  that  occurs  in  these  cases,  and 
Strauss  adopted  the  method  of  intraperitoneal  injection  as  the  quickest  means 
of  absolutely  identifying  the  disease  by  implication  of  this  organ.  He  was 
led  to  adopt  this  method  on  account  of  the  difficulties  attending  the  inoculation 
of  animals  with  the  products  of  the  disease.  Subcutaneous  injections  in  dogs 
do  not  always  give  definite  results,  and  the  inoculation  of  less  susceptible 
animals — e.  g.  guinea-pigs — is  unsatisfactory  because  of  the  length  of  time 
before  death,  twenty-five  to  thirty  days.  Field-mice  and  marmots  succumb 
in  two  to  five  days,  but  these  animals  are  often  difficult  of  access. 

After  the  intraperitoneal  injection  of  the  discharges  of  glanders  into  the 
bodies  of  male  guinea-pigs  there  is  observed  first,  as  a  prominent  lesion,  affec- 
tion of  the  testicle  as  early  as  the  second  to  the  third  day.  The  scrotum 
becomes  tense,  red,  and  shining ;  the  epidermis  desquamates.  Suppuration 
speedily  occurs  to  perforate  the  integument,  and  in  the  pus  is  to  be  found  the 
bacillus  mallei.  The  animal  succumbs  at  some  time  between  the  fourteenth 
and  fifteenth  days.  The  complication  results  also  under  subcutaneous  injec- 
tion, but  much  later,  ten  to  twelve  days.  Ijofflor  showed  that  it  was  not  only 
the  tunica  vaginalis,  but  also  the  parenchyma  itself,  which  showed  nodules 
of  the  disease.  The  tunica  vaginalis  is  covered  with  granulations,  and  by 
the  third  to  the  fourth  day  its  layers  are  agglomerated  by  an  exudation 
of  pus  rich   with   bacilli. 

A  means  of  diagnosis  is  also  offered  with  the  injection  of  mallein  (Preusse), 
which,  as  in  the  case  of  tuberculin  in  tuberculosis,  produces  a  peculiar  reaction 
in  glanders. 

The  prognosis  in  a  case  of  acute  glanders  is  absolutely  unfavorable.  The 
only  possible  rescue  may  result  from  the  speedy  destruction  and  thorough 
annihilation  of  the  first  infection.  Nearly  all  of  the  acute  and  more  than  half 
of  the  chronic  cases  succumb  to  the  disease. 

Prophylaxis. — Animals  affe(;ted  with  glanders  are  to  be  isolated  and 
killed.  According  to  the  records  of  the  Berlin  Health  Office  (1890),  there 
were  reported  as  affected  with  glanders  1337  horses;  80  died,  93  were  killed 
at  the  request  of  their  owners.     There  were  destroyed  by  the  police  1598 


518 


GLANDERS. 


animals.  In  all,  1771  horses  perished.  For  those  killed  by  the  police 
there  was  paid  by  the  state  459,834.08  marks  indemnity. 

The  cadaver  is  to  be  cremated  or  buried  deep.  Litter  and  fodder  are  to  be 
likewise  burned,  and  stables  thoroughly  disinfected.  All  persons  who  have 
come  in  contact  with  infected  horses  should  be  warned  of  danger. 

Treatment. — Local  depots  are  to  be  treated  thoroughly  and  promptly  by 
the  application  of  the  actual  cautery,  strong  carbolic  acid,  mineral  acids,  and 
corrosive  sublimate.  Chronic  cases  are  to  be  supported  with  quinine,  arsenic 
(Gamgce),  and  alcohol. 


I 


FOOT-AND-MOUTH  DISEASE. 

By  JAMES  T.  WHITTAKER. 


Synonyms. — Lat.  Ai)hth8e,  from  Greek  aupdm  (Galen),  Epizooticse;  Ger. 
Maulklaiienseuche,  Klauenseuche ;  Fr.  Stomatitie  aphtheuse ;  It.  Febbre 
aftosa. 

Definition. — A  mild,  acute  infection  of  the  lower  animals,  especially  of 
cattle,  sheep,  pigs,  less  frequently  of  the  goat,  horse,  much  more  rarely  of 
fowls,  dogs,  and  cats ;  evidently  caused  by  a  peculiar  micro-organism  not  yet 
exactly  defined  ;  characterized  by  tiie  formation  of  vesicles  and  ulcers  in  the 
mucous  membrane  of  the  mouth,  with  the  development  of  eruptions  and  ulcers 
in  crevices  about  the  feet,  sometimes  about  the  udder,  communicable  to  man 
for  the  most  part  through  the  milk  of  diseased  animals,  to  appear,  with  malaise 
and  light  fever,  as  vesicles  and  ulcers  in  the  mouth,  of  benign  course  and  short 
duration. 

Tiie  disease  was  recognized  in  animals  in  antiquity,  but  was  in  the  early 
history  of  veterinary  medicine  evidently  confounded  with  anthrax  and  actino- 
mycosis. Hierocles,  a  Greek  veterinary  surgeon,  seems  to  have  been  familiar 
with  it.  Livy  certainly  described  it.  Fracastorius  (1513)  speaks  of  the 
vesicles  in  the  mouth  and  cleft  of  the  hoof  as  they  occurred  in  animals  in 
an  epidemic  in  Italy  and  France.  Sagar  (1764)  first  noticed  the  disease  in 
man  as  caused  bv  the  ino-estion  of  the  milk  of  cows.  It  was  attended  with  a 
sense  of  iieat  and  dryness  in  the  mouth  and  throat  and  difficulty  of  swallow- 
ing, due  to  an  inflammation  and  aphtha}  which  were  to  be  observed  in  the 
mouth.  Brosche  (1820)  first  saw  eruptions  upon  the  fingers  and  toes  in  the 
case  of  two  yoiuig  girls  who  had  to  do  with  diseased  cows.  Bollinger  makes 
mention  of  an  epidemic  which  prevailed  in  Bohemia  in  1827,  affecting  both 
man  and  mule.  Hertwig  (1834)  established  the  contagiousness  of  tlie  disease 
by  cxj)erimenting  upon  himself  and  two  other  medical  men.  They  drank 
daily  for  four  days  a  quart  of  fresh  milk  from  diseased  cows.  Symptoms  of 
fever,  headache,  dryness  and  heat  in  the  mouth,  and  it<,'hing  in  the  hands  and 
fingers  began  in  two  and  lasted  for  five  days,  at  the  end  of  which  time  vesicles 
a|)peared  in  the  mouth.  The  disease  has  now,  therefore,  a  recognized  place  in 
human  ])athol(»gv.  Though  benign  in  its  manifestations  and  course,  it  is  never- 
theless a  serious  affection,  from  the  fact  that  so  many  young  animals,  sucklings, 
succumb  on  account  of  degradation  of  the  milk.  It  is  stated  that  in  some 
epizootics  as  many  as  75  per  cent,  of  surkiug  calves  perished.  The  disease, 
once  developed,  is  exceedingly  i)ersistent  ;  stables  remain  infectious  for  a  long 

51!) 


520  FOOT-AND-MOUTH  DISEASE. 

time.  It  is  then  gradually  transported  along  the  lines  of  travel,  hence  along 
the  courses  of  rivers,  and  with  a  general  tendency  westward,  to  assume  at  times 
very  wide  range.  Thus  in  the  year  1871,  700,000  animals  were  attacked  in 
England  alone,  entailing  in  the  same  year  in  France  a  loss  of  30,000,000 
francs.  In  1869  the  disease  ranged  over  nearly  all  Europe.  Switzerland 
alone  loses  by  it  about  10,000  francs  per  year.  It  makes  up  for  its  mildness 
by  its  range,  and  costs  a  country  more  than  the  malignant  diseases,  anthrax, 
glanders,  and  rinderpest. 

The  infectious  principle,  evidently  a  micro-organism,  has  not  yet  been  dis- 
tinctly isolated.  It  is  certainly  distinctly  communicable  by  inoculation. 
Nesswitzky  (1891)  conveyed  it  with  the  contents  of  vesicles  and  secretion 
of  ulcers  as  well  as  with  milk.  The  period  of  incubation  is  variously  stated 
at  one  to  twelve  days.  Some  of  the  animals  were  attacked  in  twenty-four 
hours  after  inoculation,  some  not  until  four  or  five  days,  some  not  until  five  to 
seven  days.  Inoculation  failed  in  the  experiments  of  the  Berlin  Health  Office 
in  30.3  per  cent,  of  cases.  Klein  (1886)  in  his  studies  of  the  disease  in  sheep 
eliminated  a  streptococcus  which  he  believed  to  be  the  cause  of  the  disease.  It 
had  much  resemblance  to  the  streptococcus  pyogenes.  Pure  cultures  of  it 
injected  subcutaneously  developed  in  sheep  no  symptoms  of  the  disease.  On 
the  other  hand,  sheep  fed  with  these  pure  cultures  showed  the  typical  symptoms 
of  foot-and-mouth  disease.  The  curious  observation  was  made  with  these 
studies  that  animals  previously  treated  to  subcutaneous  injections  remained 
exempt  after  feeding  experiments.  Klein  hence  concluded  that  inoculation 
conferred  immunity.  Some  doubt  pertains  to  these  conclusions,  because  of 
the  lack  of  control  experiments  and  the  means  of  excluding  spontaneous 
infection.  The  immunity  conferred  by  inoculation  is  a  discord  in  the  records 
of  artificial  immunity.  The  infectious  matter  exists  in  the  contents  of  the 
vesicles,  in  the  saliva,  in  nearly  all  the  secretions,  and  certainly  in  the  blood 
and  milk. 

Siegel  found  in  an  epidemic  of  stomatitis  in  man  a  very  delicate  bacterium, 
ovoid  in  shape,  an  elongated  coccus  or  a  very  short  bacillus,  which  developed 
in  agar  or  gelatin  without  fluidifying  the  soil  and  without  being  colored  in  the 
usual  way.  He  believed  it  to  be  derived  from  cattle  affected  with  foot-and- 
moutli  disease. 

Schottelius  in  his  studies  discovered  a  peculiar  streptococcus,  some  examples 
of  which  were  rounded,  while  others  had  a  peculiar  elongation  or  protuberance 
like  that  which  shows  in  the  prolongations  of  white  blood-corpuscles.  He  called 
these  bodies  strcptocytes.  They  differed  in  many  j)articulars  from  the  ordi- 
nary streptococcus,  but  gave  only  negative  results  in  inoculations  of  various 
animals.  Schottelius  was  never  able  to  observe  the  micro-organisms  described 
by  Siegel  in  cases  of  foot-and-mouth  disease. 

The  disease  shows  itself  in  the  lower  animals  as  a  mild  fever  attended  with 
a  catarrhal  inflammation  of  the  mucosa  of  the  mouth.  There  soon  develops 
on  the  inner  surface  of  the  lips  and  along  the  edge  of  the  jaw,  where  the  teeth 
are  absent,  at  the  tip  and  borders  of  the  tongue,  yellowish-white  vesicles,  which 


iS  YMPTOMA  TOL  OGY.  521 

show  later  purulent  contents,  and  rupture  in  the  course  of  one  to  two  days,  to 
leave  superficial  erosions  and  ulcers.  The  ulcers  heal  in  the  course  of  three  to 
six  days. 

The  affection  of  the  feet  may  show  itself  at  the  same  time  or  later  than 
that  of  the  mouth.  In  the  clefts  and  at  the  crown  of  the  hoofs  there  is 
to  be  observed  the  development  of  the  same  vesicles,  which  rupture  to  dis- 
charge purulent  contents,  which  in  turn  inspissate  to  form  crusts  and  leave 
more  or  less  extensive  ulcers.  The  affection  of  the  feet  renders  the  animal 
unable  to  stand  or  walk,  so  that  at  the  height  of  the  disease  it  must  maintain 
the  recumbent  posture.  Similar  appearances  are  to  be  observed  also  about 
the  udder,  especially  at  the  orifices  of  the  milk-ducts.  Thus,  vesicles,  pustules, 
crusts,  and,  in  consequence  of  their  detachment,  more  or  less  extensive  ulcers, 
show  themselves  about  the  bag.  The  milk  of  the  affected  animal  is  altered  in 
quantity  and  (piality.  It  is  reduced  often  as  much  as  one-half  in  the  human, 
assumes  a  yellowish  colostrum-like  appearance,  and  coagulates  prematurely. 
It  has  a  bitter,  nauseating  taste  and  develops  a  dark-yellow  sediment.  The 
disease  terminates  usually  in  twelve  to  fourteen  days. 

Man  is  usually  affected  throu«;h  diseased  milk,  which  retains  its  infection 
even  when  added  to  coffee  or  when  diluted  with  normal  milk  in  the  proportion 
of  1  to  10.  Boiling  absolutely  destroys  the  poison  in  the  milk  and  I'enders  it 
perfectly  harmless.  It  is  doubtful  if  the  disease  can  be  conveyed  by  the  meat 
of  diseased  animals,  but  instances  of  infection  have  been  reported  from  the 
ingestion  of  butter  and  cheese  made  from  the  milk  of  diseased  cows.  Infec- 
tion by  direct  inoculation,  as  in  milking,  is  not  uncommon  in  those  who  have 
the  care  of  diseased  animals. 

The  chief  interest  in  connection  with  foot-and-mouth  disease  occurs  in  rela- 
tion to  aphtha,  which  is  declared  to  be  the  expression  of  the  disease  in  man. 
It  has  been  observed  that  aphtha  prevails  coincidently  with  outbreaks  of  the 
foot-and-mouth  disease  in  cattle.  What  lends  also  especial  suj)p()rt  to  this 
view  is  the  fact  that  the  appearance  of  the  disease  is  much  the  same  in  man 
as  in  animals.     The  question  is  not  yet  settled. 

The  period  of  incubation  in  man  ranges  from  three  to  five  days.  The 
disease  may  begin  with  chills  or  chilly  sensations,  followed  by  fever,  anorexia, 
and  malaise.  Vesicles  now  appear  upon  the  inner  surface  of  the  lips  and 
tongue  along  with  a  sense  of  heat  and  dryness  ;  there  is  difficulty  in  speak- 
ing, chewing,  and  swallowing.  The  mucous  membrane  is  very  much  reddened 
and  swollen,  and  saliva  flows  abundantly.  There  is  also  often  noticed  at  this 
time  a  vesicular  eruption  on  the  fingers  and  hands,  sometimes  in  association 
with  intestinal  disturbance.  The  vesicles  upon  the  fingers  are  at  first  small 
and  trans])arent.  They  soon  increase  in  size,  and  change  in  color  to  show 
purulent  contents,  and  sometimes  closely  simulate  the  eruptions  of  small-pox. 
Cases  have  been  reported  where  the  eruj)li<)U  was  so  extensive  as  to  cover  the 
entire  body  (Biercher).  Ilolni  saw  vesicles  on  the  nipj)le  of  a  woman  who 
drank  daily  large  f|tiaiitities  of  milk    from  cows  alfected  with  the  disease. 

Tiie  catarrhal   inflammation   may  assume  such  |)roj)orlion   as  to  constitute 


522  FOOT-AXn-MOUTH  DISEASE. 

an  extensive  stomatitis.  Briscoe  saw  a  case  in  which  the  tongue  was  so  much 
swollen  as  to  project  more  than  an  inch  from  the  mouth. 

Prophylaxis  includes  proper  care  of  the  animal  regarding  pasturage  and 
stables.  Man  is  best  [)rotected  by  the  ingestion  of  milk  from  healthy  cows, 
or,  if  that  be  impossible,  by  the  thorough  boiling  of  milk  from  diseased  cows. 

The  diagnosis  is  usually  easy.  It  may  be  known  that  the  disease  exists 
at  the  time  in  animals.  The  peculiar  coincidence  of  eruption  in  the  mouth 
and  extremities,  sparing  the  rest  of  the  body,  is  unlike  any  other  eruptive 
disease.  Thus,  the  mycoses  of  the  mouth  are  unattended  with  affection  of  the 
feet,  and  eczematous  and  other  eruptions  of  the  feet  are  unassociated  with 
eruptions  in  the  mouth. 

The  prognosis  is  favorable.  The  disease  runs  a  mild  course,  and  termi- 
nates, as  a  rule,  in  from  five  to  eight  days.  Extensive  affection  of  the  hands, 
with  the  difficulty  of  proper  protection,  may  extend  the  disease  to  several 
weeks.     Fatal  cases  have  been  reported  in  very  delicate  children. 

Treatment. — Stomatitis  is  best  treated  with  weak  solutions  of  borax  as 
mouth-washes.  Erosions  and  ulcers  should  be  cauterized  with  the  nitrate  of 
silver,  which  not  only  protects  an  abraded  surface  from  irritating  contact,  but 
also  by  its  antimycotic  properties  directly  addresses  itself  to  the  cause  of  the 
disease.  The  superficial  lesions  of  the  extremities  may  be  best  treated  by  lead 
washes,  diachylon  ointment,  light  bandages,  etc.  The  fever  and  general  dis- 
tress of  infection  may  call  for  mild  or  repeated  doses  of  phenacetin,  chloral,  or 
Dover's  powder. 


GENEPxAL  SYMPTOMATOLOGY  OF  DISEASES  OF 

THE  NERVOUS  SYSTEM. 


By  HORATIO  C.  WOOD. 


The  symptoms  of  disease  of  the  nervous  system  are  due  to  disturbance  of 
the  functions  either  of  the  nerve-centres  or  of  the  peripheral  nerves,  and  are 
therefore  best  studied  in  outline  under  the  headings  of  Motion,  voluntary  and 
reflex  ;  Co-ordination  ;  Sensation  ;  Vaso-motor  and  Trophic  Alterations ;  and 
Disturbance  of  Intellection,  including  memory,  speech,  and  emotion. 

Motion. 

Paralysis,  or  true  loss  of  motor  power,  must  be  distinguished  from  the 
loss  of  motion  due  to  local  disease  and  to  arrest  of  function  of  the  muscles  or 
of  the  joints  by  pain  on  movement.  This  ])seudo-paralysis  can  usually  be 
recognized  by  the  fact  that  passive  motion  and  local  pressure  give  pain.  It 
must  be  remembered,  however,  that  when  contractures  exist  or  when  peripheral 
nerves  are  diseased  true  paralysis  may  exist,  although  passive  movements  are 
painful. 

Paralysis  may  be  complete  or  incomjilete.  Wiien  it  affects  the  whole  body 
below  the  head  it  is  spoken  of  as  a  General  Paralysis.  A  general  paralysis 
can  never  be  absolutely  complete,  since  the  subject  muse  die  from  loss  of  pow- 
er in  the  respiratory  muscles  before  such  condition  is  reached.  Hemiplegia, 
strictly  speaking,  is  a  paralysis  of  one  lateral  half  of  the  body,  but  the  term 
is  universally  used  not  only  when  one-half  of  the  face,  arm,  and  leg  are  para- 
lyzed, but  also  when  only  the  arm  and  leg  of  one  side  are  affected.  It  is  indeed 
very  rare  for  the  trunkal  muscles  to  participate  in  a  hemiplegia.  A  spinal 
hemiplegia  is  conceivable,  but  in  fact  hemiplegia  is  almost  universally  of  brain 
origin. 

Paraplegia  is  paralysis  of  the  lower  transverse  half  of  the  body  :  with  the 
rarest  exceptions  it  is  spinal.  Monoplegia,  paralysis  of  one  part,  may  ha  facial, 
brachial,  or  crural.  It  may  be  due  to  lesion  of  the  brain,  of  the  spinal  cord, 
or  of  the  nerve-trunk.  A  cerebral  lesion  causing  monoplegia  is  almost  always 
cortical,  and  a  spinal  lesion  is  almost  invariably  situated  in  the  ganglionic  cells 
in  the  anterior  cornua. 

A  Local  Paralysis — i.e.  a  palsy  of  a  single  muscle  or  muscle-group — is 
produced  by  lesions  situated  like  those  of  monoplegia,  but  less  extensive.  A 
Multiple  Paralysi.'i  is  a  ]xiralysis  of  more  or  less  scattered  groups  of  muscles  not 
directly  connected  either  fimctionally  or  anatomically  with  one  another,  and 
may  be  looked   uj)on  as  an  association  of"  local  palsies.     It  is  usually  due  to 

523 


524  SYMPTOMATOLOGY    OF  NERVOUS   DISEASES. 

disease  of  various  groups  of  8j)inal  ganglion-cells,  but  may  be  peripheral,  and 
in  rare  cases  is  the  outcome  of  multiple  cortical  brain  lesions.  In  paralysis 
of  the  face  the  mouth  is  always  drawn  toward  the  opposite  side,  unless  con- 
tractures in  the  paralyzed  muscles  have  taken  place,  when  the  mouth  may  be 
drawn  toward  the  paralyzetl  side.  In  paralysis  of  half  of  the  tongue  the  tip 
in  motion  turns  toward  the  paralyzed  side.  In  the  examination  of  the  para- 
lytic it  is  customary  to  note  the  exact  power  of  grasp  by  means  of  the 
dynamometer  :  a  pulley  and  weight  apparatus  may  be  used  for  the  upper  arm 
and  leg,  but  in  practice  a  sufficiently  accurate  judgment  may  be  made  by 
noting  the  extent  of  forced  movements,  the  endurance  in  walking  or  in  stand- 
ing on  one  leg,  the  ability  to  get  out  of  a  chair,  etc. 

Convulsions. — Three  types  of  convulsions  are  recognized :  the  epUepti- 
forin  or  cerebral,  in  which  consciousness  is  completely  lost ;  the  hysterical,  in 
which  consciousness  is  disturbed ;  and  the  tetanic  or  spinal,  in  which  con- 
sciousness is  normal  and  reflex  activity  grossly  exaggerated.  In  nature  these 
varieties  of  convulsions  grade  imperceptibly  one  into  the  other.  A  detailed 
discussion  of  convulsions  will  be  found  in  various  articles,  especially  in  those 
on  epilejisy  and  hysteria. 

Automatic  Movements. — The  condition  sometimes  seen  in  epilepsy  and 
in  various  abnormal  states,  in  which  a  series  of  seemingly  voluntary  acts  are 
performed  without  clear  consciousness,  is  spoken  of  as  automatism.  An  auto- 
matic act  often  involves  an  elaborate  series  of  movements,  such  as  those  that 
occur  in  bowing,  getting  out  of  a  chair,  and  the  like.  The  chorea  major  of 
some  German  writers  represents  a  form  of  automatism,  and  has  no  relation 
with  true  chorea  or  choreic  movements.^ 

Reflexes. — For  the  performance  of  a  reflex  action  an  arc  composed  of  affer- 
ent nerve,  motor  ganglion-cell,  efferent  nerve,  and  muscle  must  be  complete. 
Disturbances  of  reflex  activity  must  be  due  to  disturbances  of  this  arc,  in  which 
are  of  course  included  such  portions  of  the  nerve-fibres  as  are  in  the  nerve-roots 
and  spinal  cord  itself. 

The  superficial  reflexes  are  excited  by  irritations  of  the  skin  and  mucous 
membrane,  either  by  tickling,  pricking,  pinching,  or  gently  scratching  the  sur- 
face, or  by  means  of  a  dry  electric  brush.  As  the  superficial  reflexes  are  not 
constant  in  the  normal  individual,  the  absence  of  a  skin  reflex  is  of  uncertain 
diagnostic  import,  whilst  the  presence  of  the  reflex  shows  the  integrity  of  the 
nerve-arc  implicated.  The  most  important  of  the  superficial  reflexes  are  :  the 
plantar  reflex,  contraction  of  leg,  evoked  by  tickling  the  sf)le  of  the  foot — reflex 
arc  involving  the  lower  end  of  the  cord ;  the  gluteal  reflex,  consisting  of  con- 
tractures of  the  gluteal  muscles  produced  by  stimulating  the  skin  of  the  but- 
tocks— arc,  through  the  fourth  and  fifth  lumbar  nerves  ;  the  cremasier  reflex, 
causing  the  drawing  up  of  the  testicle  when  the  skin  of  the  inner  side  of  the 
thigh  is  stimulated — arc,  the  first  and  second  pair  of  lumbar  nerves  and  their 
spinal  centres ;  tiie  abdominal  reflex,  causing  contractions  of  the  abdominal 

'  The  confusion  is  made  still  worse  by  the  fact  that  some  Continental  writers  speak  of  very 
bad  cases  of  St.  Vitus's  dance  as  chorea  riuujna. 


MOTION.  525 

muscles,  cliiefly  the  rectus,  when  the  skin  of  the  sides  of  the  abdomen  is  stroked 
from  the  ribs  downward — arc,  from  the  eighth  to  the  twelfth  dorsal  nerves; 
the  epigastric  refiex,  causing  a  dimpling  of  the  epigastrium  on  the  stimulation 
of  the  same  side  of  the  chest  in  the  sixth  and  fifth  intercostal  spaces,  and  some- 
times even  in  the  fourth — arc,  from  the  fourth  to  the  seventh  pair  of  dorsal 
nerves;  the  erector-spinal  re/lex,  causing  contraction  of  the  erector-spinfc  muscles 
when  the  skin  along  their  edges  is  stimulated — arc,  in  the  dorsal  region  of  the 
spinal  cord  ;  the  scapular  rejiex,  causing  contraction  of  some  or  nearly  all  of 
the  scapular  muscles  on  superficial  irritation  of  the  scapular  region — arc,  the 
upper  two  or  three  dorsal  and  lower  two  or  three  cervical  nerves;  the  palmar 
refcx,  producing  contraction  of  the  flexors  of  the  fingers  on  tickling  the  palm  of 
the  hantl — arc,  through  the  cervical  enlargement  of  the  cord  ;  cranial  reflexes, 
such  as  contractions  of  the  palatal  muscles  by  irritation  of  the  fauces,  sneezing 
bv  irritation  of  the  nasal  mucous  membrane,  cough  bv  irritation  of  the  larynsreal 
mucous  membrane,  closing  of  the  eyes  by  irritation  of  the  conjunctiva,  move- 
ments of  the  iris  by  light. 

Of  the  deep  reflexes — that  is,  of  those  connected  with  such  deep-seated  tissues 
as  tendons  and  bones — the  most  important  are  elicited  by  striking  the  patella 
tendon  ( WestphaVs  symptom,  patella  reflex,  knee-jerk)  or  by  flexing  the  foot 
forcibly,  so  as  to  stretch  the  Achilles  tendon  {ankle  clonus).  In  some  cases 
tap])ing  of  the  biceps  or  flexor  tendons  in  the  arm  will  produce  contractions  of 
the  muscles;  a  jaw  or  chin  reflex  is  obtained  by  allowing  the  jaw  to  hang  pas- 
sively or  by  gently  supporting  it  with  one  hand  whilst  with  the  other  the  blow 
is  struck  on  the  chin  with  a  hanmier  in  a  downward  direction.  Ankle  clonus  ^ 
is  never  (elbow-,  wrist-,  and  jaw-jerks  rarely)  present  in  normal  individuals. 
In  testing  the  knee-jerk  the  bared  leg  is  so  supported  that  the  foot  swings  free 
from  the  floor,  and  the  tendon  above  or  below  the  patella  is  struck  with  the 
edge  of  the  hand,  with  the  fingers,  or  with  a  small  hammer  having  an  elastic 
steel  handle  and  an  India-rubber  head.  Any  vohmtary  movement,  such  as 
clinching  the  hands  at  the  time  of  the  delivery  of  the  blow,  increases  (techni- 
cally, "  reinforces")  the  contraction.  Tiie  knee-jerk  is  probably  absent  in  about 
2  \^eY  cent,  of  normal  indivi<luals. 

Paradoxical  Contractions  are  contractions  which  in  certain  diseased  con- 
ditions are  produced  by  suddenly  relaxing  the  muscle,  as  may  happen  to  the 
anterior  muscles  of  the  leg  when  the  foot  is  forcibly  flexed. 

Spasms — i.  e.  involuntary,  not  permanent,  contractions  of  muscles — may 
be  clonic,  that  is,  of  brief  duration  with  intervals  of  relaxation  ;  may  be  tonic, 
that  is,  prolonged  without  intervals  of  relaxation.  The  permanent  shortening 
or  contraction  of  the  muscles  is  spoken  of  as  a  contracture.  This  contractiu'c 
may  be  due  to  disease  of  the  muscle  itself  or  the  nerve-centres  to  which  it 
is  tributary,  or  may  be  the  outcome  of  a  lack  of  power  in  the  antagonistic 
muscles. 

A  Tremor  is  a  to-and-fro,  vibratilc  movement  which  is  produced  by  more 

'  A  clonus  is  a  to-and-fro  vibratory  movement,  and  in  aises  with  highly  exaggerated  reflexes 
can  somotimos  l)e  produced  in  other  joints  than  the  ankle. 


526  SY3IPTOMATOLOGY   OF  NERVOUS   DISEASES. 

or  less  rhvthinical,  successive  contractions  of  antagonistic  muscles.  It  does 
not  in  any  way  simulate  voluntary  movements.  Tremors  are  of  two  kinds : 
tremors  which  occur  whether  the  part  be  at  rest  or  in  motion  ;  and  tremors 
{intention  tremors)  which  occur  only  upon  movement  of  the  part  affected  or 
of  some  other  portion  of  the  nervous  system.  Intention  tremors  are  almost 
invariably  the  outcome  of  a  multiple  cerebro-spinal  sclerosis.  Persistent 
tremors  may  be  due  to  old  age,  to  alcohol,  tobacco,  or  other  poisons,  to  general 
paralysis,  or  to  paralysis  agitans.  In  some  cases,  especially  in  mercurial  poison- 
ino-,  the  toxic  tremor  may  simulate  an  intention  tremor.  Senile  tremors  may 
also  sometimes  cease  during  absolute  repose. 

Choreic  Movements  may  be  defined  to  be  irregular  movements  produced 
by  independent  contractions  of  single  or  associated  groups  of  muscles,  not 
vibratory  in  character,  and  more  or  less  simulating  purposive  movements,  but 
never  forming  a  complicated  series  of  apparently  purposive  actions.  They 
may  vary  in  intensity  from  the  slightest  irregular  movements  of  the  fingers 
or  toes,  or  even  a  mere  condition  of  excessive  muscular  activity  resembling 
restlessness,  up  to  the  most  severe  and  violent  motions.  They  may  be  con- 
fined to  a  single  group  or  to  associated  groups  of  muscles  {local  chorea),  or 
may  affect  the  entire  muscular  system  {general  chorea).  When  the  whole  body 
is  affected  the  muscular  contractions  do  not  take  place  regularly  or  consen- 
taneously, but  momentarily,  here  and  there.  In  some  cases  they  are  under  the 
control  of  the  will  for  a  short  period  of  time,  but  always  assert  themselves 
in  a  few  minutes.  The  choreic  movement  is  usually  irregular,  but  it  may  be 
rhvthmical.  Rhythmical  choreas  more  or  less  closely  resemble  tremors,  dif- 
fering chiefly  in  that  the  movements  are  much  slower  and  more  extensive. 

The  term  "  chorea  "  has  been  frequently  used  in  literature  as  synonymous 
with  choreic  movements,  and  has  also  been  applied  to  many  diseases  of  an 
entirely  diverse  nature.  Lesions  of  any  of  the  ganglionic  cells  connected  with 
the  cerebral  or  pyramidal  tract — that  is,  of  the  tract  commencing  in  the  brain 
cortex  and  ending  in  the  motor  cells  of  the  anterior  cornoa  of  the  spinal  cord 
— may  produce  choreic  movements,  so  that  the  choreic  movement  is  not  more 
uniform  in  its  significance  than  is  paralysis. 

Generalized  choreic  movements  (chorea  of  many  authors)  may  be  due  to 
8t.  Vitus's  dance ;  to  reflex  irritation  ;  to  organic  disease  of  the  nerve-centres, 
including  in  this  cases  of  chorea  in  the  insane  ;  to  pregnancy  ;  to  Huntingdon's 
disease ;  to  changes  in  the  nervous  centres  occurring  in  old  age ;  to  hysteria. 

Local  choreas  have  little  or  no  relation  with  general  chorea.  Some  local 
choreas  are  probably  reflex,  as  in  those  cases  in  which  violent  local  chorea 
develops  briskly  in  the  course  of  an  acute  internal  inflammation,  such  as  pleu- 
risy or  pneumonia.  In  other  local  choreas  {habit  choreas)  the  spasmodic  move- 
ments have  their  origin  during  childhood  in  a  frequently  repeated  purposive  act 
which  has  grown  in  a  neurotic  temperament  into  a  fixed  habit  of  the  nervous 
system,  no  longer  under  the  control  of  the  person.  A  brow  may  be  lifted  at 
intervals,  a  shoulder  shrugged,  an  eye  winked,  a  jaw  dragged  forward,  a  trick 
of  gesture  incessantly  repeated,  even  a  cough  or  a  sniffle  perpetually  indulged  in. 


CO-  OHDINA  TIOX.—SAWSA  TION.  527 

The  habit  cliorca  has  a  tendency  not  only  to  become  more  and  more  uncon- 
trollable with  years,  but  also  to  increase  in  its  range.  It  is  probable  also  that, 
in  the  beginning,  some  of  these  protracted  habit  choreas  are  not  purely  volun- 
tary movements,  but  are,  at  least  in  part,  due  to  a  functional  disturbance  of 
the  affected  nerve-centres. 

Co-ordination. 

The  function  of  co-ordination — /.  e.  the  mutual  action  or  reaction  of  mus- 
cles that  completed  movements  may  be  performed — may  be  disturbed  in  the 
whole  organism  or  in  the  arms  or  legs  separately.  When  loss  of  co-ordination 
is  slight  some  care  is  necessary  to  detect  it.  If  a  normal  individual  be  placed 
in  a  strictly  erect  position,  with  the  heels  and  toes  of  the  two  feet  closely 
approximated,  a  certain  amount  of  swaying  of  the  body  occurs,  especially 
if  the  eyes  be  shut.  If,  however,  there  be  loss  of  co-ordinating  power,  this 
swaying  is  greatly  augmented.  This  so-called  "position  test"  becomes  more 
severe  and  difficult  if  the  patient  be  required  to  stand  on  one  foot.  In  a 
doubtful  case  the  patient  should  be  required  to  stand  alternately  on  each  foot, 
to  walk  backward,  and  to  attempt  to  turn  suddenly.  Any  marked  awkward- 
ness in  these  actions  should  give  rise  to  suspicion. 

In  making  the  various  tests  the  practitioner  must  beware  of  mistaking  for 
true  loss  of  co-oi'dination  the  inability  that  arises  from  muscular  weakness, 
from  muscular  stiffness,  or  from  the  vertigo  of  cerebral  disease.  Especially  is 
titubation  (see  Brain  Diseases)  not  to  be  confounded  with  the  loss  of  co- 
ordination. 

The  co-ordination  in  the  arms  is  tested  by  the  power  of  executing  delicate 
movements.  Thus,  the  patient  may  be  told  to  close  the  eyes,  clench  the  hands 
with  extension  of  the  index  finger,  extend  the  arms  widely,  and  rapidly  bring 
the  index  fingers  together.  If  co-ordination  be  imperfect,  the  points  of  the 
fingers  will  not  come  in  contact. 

Sensation. 
In  the  study  of  sensation  it  is  necessary  to  distinguish  algesia,  or  the  power 
of  feeling  pain,  from  sensibility.  Sensibility  itself  must  also  be  redivided 
into  the  sense  of  touch,  or  the  power  of  recognizing  contacts  ;  electrical  sen- 
sibility, or  the  power  of  recognizing  electrical  currents  ;  thermic  sensibility,  or 
the  power  of  recognizing  the  temperature  of  bcxlies  ;  pressure  sense,  or  tiic 
jKAver  of  recognizing  weights;  and  the  muscular  sense,  or  the  power  of  esti- 
mating muscular  movements.  In  all  testing  of  sensibility  the  doctor  has  to 
depend  upon  the  statements  of  the  patients,  and  care  is  sometimes  necessary  to 
avoid  being  misled.  When  great  accuracy  is  required  the  sense  of  touch  may 
be  tested  by  means  of  the  aisthesiometer.  This  consists  of  a  pair  of  ordinary 
compasses  with  blunted  points,  furnished  with  a  graduated  scale,  or  of  a  j>Mir 
of  points,  one  of  which  slides  uj)on  a  bar  s(^  that  the  distance  between  the 
points  when  separated  is  known.  On  the  surface  of  tlic  butly  these  points  arc 
ielt  as  tw(j  points  or  as  a  single  point  according  as  they  are  more  or  less  widely 


o28  SYMPTOMATOLOGY   OF   NERVOUS    DISEASES. 

separated  and  as  the  skin  is  more  or  less  sensitive.  The  sensibility  varies 
greatly  in  different  parts  of  the  skin  and  also  on  the  same  portion  of  the  skin 
in  different  individuals.  Any  wide  deviation  from  the  following  scale  may, 
however,  be  regarded  as  pathological :  the  top  of  the  tongue,  1.18  mm. ;  the 
end  of  the  fingers,  2.25  mm. ;  the  side  of  the  first  phalanx,  16  mm. ;  the  back 
of  the  hand,  3.1  mm. ;  the  upper  arm  and  thigh,  3.7  mm.  The  smallest 
required  distance  is  ofitener  less  in  the  transverse  than  in  the  longitudinal 
direction  of  the  limbs.  In  practice  it  will  usually  be  found  better  to  compare 
the  affected  part  with  the  opposite  side  of  the  body,  rather  than  with  any 
theoretic  formula.  Care  should  always  be  taken  to  apply  the  points  simul- 
taneously and  with  equal  force. 

The  sense  of  pressure  is  tested  by  laying  the  hand,  foot,  etc.  upon  a  firm, 
hard  surface,  like  that  of  a  table,  and  placing  graduated  weights  upon  it. 
Several  forms  of  apparatus  have  been  devised.  A  very  convenient  method  is 
to  more  or  less  partially  fill  a  series  of  ordinary  shot-gun  cartridge-shells  with 
shot,  so  as  to  form  a  regular  series  of  weights  which  resemble  one  another 
exactly  to  the  eye. 

The  muscular  sense  may  be  tested  in  the  arms  by  testing  the  power  of  the 
patient  for  recognizing  the  amounts  of  various  weights  when  lifted. 

Thermic  sensibility  is  tested  by  tlie  alternate  application  of  hot  and  cooler 
bodies.  More  or  less  complicated  instruments  have  been  constructed  under 
the  name  of  therino-cesthesiometers,  but  vials  of  water  of  different  temperatures 
are  sufficient  for  practical  purposes.  The  temperature-range  of  most  accurate 
sensation  lies  between  27°  and  30°  C,  then  between  33°  and  39°  C,  and 
lastly  between  14°  and  27°  C.  The  variations  above  or  below  these  limits 
produce  simply  sensations  of  pain.  According  to  the  experiments  of  Noth- 
nagel,  the  smallest  perceptible  differences  of  temperature  are  the  following  :  on 
the  breast,  0.4°  C. ;  on  the  back,  0.9°  C. ;  on  the  back  of  the  hand,  0.3°  C. ; 
palm  of  the  hand,  0.4°  C. ;  arm,  0.2°  C. ;  back  of  the  foot,  0.4°  C. ;  lower 
extremities,  from  0.5°  C.  to  0.6°  C. ;  the  cheek,  0.4°  C.  to  0.2°  C. ;  the  tem- 
ples, 0.4°  C.  to  0,3°  C.  In  practice  few  normal  individuals  will  recognize,  I 
believe,  differences  of  temperature  so  small  as  those  here  mentioned. 

The  results  of  vaso-motor  and  trophic  alterations  are  so  evident  to  the 
senses  that  no  discussion  of  them  is  required  here ;  whilst  the  difficulties  that 
surround  the  apprehension  of  symptoms  due  to  disturbance  of  intellection  are 
so  great  as  to  require  elaborate  discussion  in  the  article  upon  Mental  Diseases. 


MENTAL  DISEASES. 

By  HORATIO  C.  WOOD. 


General  Considerations. 

At  least  in  the  United  States,  alienists  have  long  been  so  set  apart  from 
other  physicians  that  they  seem  hardly  to  form  an  integral  part  of  the  profes- 
sion, whilst  to  a  large  proportion  of  the  practitioners  of  medicine  the  subject  of 
insanity  is,  as  it  were,  a  closed  book,  unopened  in  the  medical  schools,  unstud- 
ied in  the  after-years.  Nevertheless,  in  the  great  majority  of  cases  the  general 
practitioner  alone  has  opportunities  to  study  the  beginning  of  mental  aberration, 
and  too  often  his  failure  to  apprehend  works  ruin  to  the  patient.  Within  the 
limits  assigned  in  the  present  volume  it  is  practically  impossible  to  write  a 
treatise  on  insanity  which  siiall  meet  the  needs  of  the  specialist,  but  it  does 
seem  to  me  possible  to  make  such  a  statement  of  the  general  principles  and 
the  important  clinical  facts  of  alienism  as  shall  serve  to  the  student  or  prac- 
titioner of  medicine  as  a  general  guide,  and  as  a  foundation  upon  which  can  be 
built,  if  wanted,  more  detailed  knowledge.  More  than  this,  I  believe  that  the 
great  danger  of  all  specialism  is  lack  of  breadth  of  view ;  and  possibly  the 
fact  that  the  writer  of  this  article  has  worked  for  fifteen  years  in  general  clini- 
cal medicine  in  the  wards  of  large  hospitals,  and  has  had  large  experience  as  a 
general  medical  practitioner,  may  give  a  flavor  to  the  writing  different  from  that 
of  the  work  of  the  pure  specialist.  Under  the  circumstances  it  has  seemed  es- 
sential to  devote  proportionately  more  space  to  the  general  consideration  of  the 
subject  than  would  be  allotted  in  a  treatise  on  insanity. 

For  the  purpose  of  studying  the  symptoms  of  mental  disorder  the  human 
intellectual  faculties  may  be  separated  into  the  will,  the  intellectual  facul- 
ties proper,  such  as  reason,  imagination,  etc.,  and  the  emotions,  such  as  fear, 
anger,  etc. 

Disorder  of  one  mental  faculty  is  almost  invariably  accompanied  by  a  greater 
or  less  degree  of  disturbance  of  the  other  mental  faculties,  but,  a  priori,  there 
seems  to  be  no  reason  why  one  faculty  of  the  mind  should  not  suffer  alone,  and 
cases  are  said  to  occur  in  practice  in  which  a  single  faculty  appears  to  be  under 
the  influence  of  disease  when  no  other  evidences  of  mental  disorder  can  be 
detected. 

The  human  will  acts  chiefly  upon  the  lower  intellectual  and  emotional  brain- 
functions  as  a  repressive  force.  It  inhibits  or  puts  aside  this  thought  or  that 
distraction  (»r  this  emotion,  rather  than  brings  forwaid  another  thought  or 
emotion.  W<'  cannot  will  oni'sclvcs  into  a  passion,  though  wc  can  by  a  direct 
effort  of  the  will  inhibit  or  repress  a  rising  anger.  IT  we  desire  to  produce  a 
fitof  anger,  we  do  it  by  bringing  before  the  mind  thoughts  which  act  as  stimu- 
Voi..  r.— :U  529 


530  MENTAL    DISEASES. 

lants  to  the  desired  emotion  :  the  almost  unconscious  recognition  of  this  fact 
has  led  to  the  expression  ''  working  one's  self  into  a  passion."  As  is  usually 
the  case  in  disorders  of  inhibitory  nerve-function,  affections  of  the  will  are 
most  plainlv  and  frequently  manifested  by  weakness  or  failure  of  power. 

It  is  true  that  the  excessive  obstinacy  and  self-assertion  so  often  seen  in 
insanitv  at  first  sight  appear  to  indicate  abnormal  exaltation  of  the  will,  but 
these  extravagances  of  thought  and  action  may  be  due  to  the  overpowering 
influence  of  some  emotion  or  some  idea  which  so  dominates  the  will  as  to  gov- 
ern entirely  the  actions  of  the  individual.  The  obstinacy  and  self-assertion  are, 
under  these  circumstances,  really  the  outcomes  of  a  weakened  will  rather  tlian 
of  an  overpowering  egoism,  the  person  being  obstinate  or  aggressive  because 
his  will  is  enslaved  by  a  lower  intellectual  or  emotional  nerve-centre.  Thus, 
in  melancholia  inflexible  obstinacy  may  result  from  the  absolute  despotism  of 
an  overwhelming  sorrow.  In  hysteria  the  will  is  probably  always  abnormally 
feeble,  but  the  persistence  and  apparent  wilfulness  of  hysterical  subjects  are 
proverbial. 

Weakness  of  the  will  is  produced  by  various  organic  bra  in -diseases  which 
lower  the  nutritive  tone  of  the  cerebral  cortex.  It  is  caused  very  frequently 
by  chronic  poisonings,  being  one  of  the  most  pronounced  symptoms  of  alco- 
holism and  of  opiumism.  Under  these  circumstances  the  subject  may  show 
an  extraordinary  determination  and  persistency  when  dominated  by  his  appe- 
tite, and  yet  he  is  really  most  infirm  of  purpose,  entirely  unable  to  decide 
upon  a  course  of  action  in  regard  to  ordinary  matters  or  to  carry  out  his  decis- 
ion when  reached.  He  is  liable  to  be  inordinately  influenced  by  his  associates 
and  by  his  environs,  cannot  resist  entreaty  and  temptation,  and  so  becomes 
more  and  more  the  sport  of  his  desires  and  of  external  influences. 

Acute  illness,  starvation,  hardships,  age,  chronic  diseases,  any  influence 
which  lowers  the  nutrition  of  the  higher  nerve-centres,  may  produce  weak- 
ness of  the  will.  So  varied  are  the  causes  of  abulia  (or  abnormal  weakness 
of  the  will)  that  the  symptoms  have  no  further  diagnostic  import  than  to  show 
a  serious  functional  or  structural  alteration  of  the  cerebral  cortex. 

Exaggeration  of  the  will-power  is  known  as  hyperbuUa,  and  reveals  itself 
in  some  forms  of  mania  and  cerebral  cortical  excitement. 

The  emotional  nature  may  be  by  disease  depressed,  exalted,  or  perverted  : 
the  alteration  often  affects  persistently  a  single  emotion  or  a  single  class  of 
emotions,  or  it  may  attack  successively,  at  shorter  or  longer  intervals,  emotions 
that  are  antagonistic.  Thus,  a  subject  may  be  in  a  continual  state  of  joy  or 
of  emotional  depression,  or  he  may  rapidly  or  slowly  pass  from  one  state  of 
emotional  excitement  to  another,  now  carried  away  by  anger,  now  prostrated 
by  fear,  now  soaring  with  joy,  now  overwhelmed  by  sadness. 

In  advanced  stages  of  cerebral  disease  a  condition  of  true  emotional  enfee- 
blement  or  lethargy  may  be  ])resent,  so  that  external  circumstances  which  nat- 
urally affect  most  vividly  this  or  that  emotion  fail  to  produce  any  response. 
This  mental  condition  ought  logically  to  be  known  as  emotional  depression. 
It  is  to  be  clearly  distinguished  from  excitement  or  over-activity  of  the  depres- 


GENERA  L    ( 'OXSIDERA  TIONS.  63 1 

sive  emotions,  such  as  sorrow,  and  their  congeners.  Viewed  in  this  way,  the 
melancholic  person  is  not  in  a  condition  of  emotional  depression,  but  in  one 
of  emotional  excitement — /.  e.  of  excitement  of  the  depressive  emotions.  Mel- 
ancholia is,  it  is  true,  fre(piently  associated  ^itli  depression  of  the  nervous 
system,  but  this  is  not  always  the  case,  and  the  victim  of  melancholia  asritata 
may  be  in  a  condition  of  general  nervous  ervthrism  as  pronounced  as  that 
which  affects  the  maniac  with  widelv-expansive  delusions.  On  the  other 
hand,  high  hopes  and  abundant  joy  are  in  advanced  general  paralysis  closely 
linked  \vith  the  most  profound  evi  lences  of  failing  nerve-puwer.  If  melan- 
cholia is  to  be  considered  a  state  of  lowered  emotional  activity,  whilst  joy 
and  anger  are  the  outcomes  of  emotional  excitement,  it  logically  follows  that 
the  antagonistic  emotions  are  different  manifestations  of  one  cerebral  function, 
joy  being  the  result  of  excessive  stimulation,  sorrow  of  excessive  depression, 
of  the  same  brain-cells — a  conclusion  which  I  think  few  persons  would  be 
ready  to  accept  as  correct. 

The  relations  between  the  diverse  emotions  of  which  I  have  just  spoken 
are  of  some  importance  as  explaining  the  fact  that  in  various  mental  affections 
mania  and  melancholia,  or  opposite  emotional  states,  may  follow  each  other, 
and  even  appear  to  be  produced  by  the  same  brain  lesion.  Thus,  in  paretic 
dementia  the  persistent  hyperseraia  of  the  brain-cortex  may  cause  thi'oughout 
the  attack  intense  sadness,  or  an  emotional  depression  may  suddenly  replace 
the  expansive  happiness  usual  to  the  affection.  To  account  for  such  a  change 
it  is  only  necessary  to  suppose  that  there  is  a  shifting  of  the  hypersemia  and 
the  excitement  from  one  portion  of  the  brain  to  another. 

The  lethargy  due  to  absolute  loss  of  mental  powder  spoken  of  on  page  552 
really  is  closely  associated  in  its  origin  and  nature  with  stupor,  differing,  how- 
ever, from  that  condition  in  that  consciousness  is  not  lost :  both  stupor  and 
emotional  lethargy  may  in  the  insane  be  closely  simulated.  An  insane  patient 
may  lie  in  bed  absolutely  still  and  inert,  with  closed  eyes,  giving  no  response 
to  the  loudest  questioning  and  making  only  a  feeble  and  slow  resistance  to  per- 
sonal violence  ;  or  when,  with  head  bent  forward,  joints  flexed,  and  face  frozen 
into  an  immobile  apathy,  he  sits  motionless  in  his  chair,  he  may  seem  to  be  lost 
in  unconsciousness,  but  none  the  less  may  he  have  knowledge  of  his  surround- 
ings and  of  his  sorrows.  The  pseudo-lethargy  may  be  the  direct  result  of  an 
intense  emotion  or  of  delusion,  and  not  be  consciously  assumed  ;  but  not 
rarely  it  is  put  on  for  a  definite  end,  and  maintained  with  a  tenacity  of  piu'- 
pose  which  defies  detection  even  during  the  intoxication  caused  by  ether  or  by 
alcohol.  The  occasional  revelations  made  by  ])atients  after  they  recover  their 
reason  show  that  a  delusion  may  act  very  directly  in  the  ])roduction  of  an 
assumed  stupor.  A  man  i)elieves  that  he  has  received  commands  from  the 
Almighty  to  isolate  himself  from  all  eonununioii  willi  his  fellows,  and  in 
maintaining  the  assumed  stupor  battles  for  his  eternal  salvation  ;  or  the  lima- 
tic  conceives  that  his  attendants  are  cons])iring  against  hiin,  and  will  do  him 
great  evil  if  once  they  are  assured  he  is  alive.  In  some  eases  the  |)seu(lo- 
^ethargv  is  the  result  of  an  overwhelming  (^notion  j)rodueed   by  the  delusion. 


632  MENTAL    DISEASES. 

The  man  about  to  be  devoured  by  foul  beasts  or  by  the  flames  of  hell  is  dumb 
through  fear,  or,  as  the  German  alienists  say,  is  thunderstruck.  Occasionally 
the  insane  sleeper  is  convinced  that  he  is  dead,  and  by  this  delusion  his  will  is. 
so  far  paralyzed  that  it  is  unable  to  act,  and  the  man  really  cannot  move,, 
althougii  the  lower  nervo-muscular  apparatus  is  intact. 

The  intellectual  functions  proper  may  suffer  from  actual  exaltation,  giving 
rise  to  increase  of  power ;  from  an  exaltation  which  is  so  unbalanced  as  tO' 
produce  a  derangement  of  action  ;  from  a  real  depression  or  loss  of  power. 

Absolute  increase  of  mental  poioer  is  a  rare  condition,  and  is  never  present 
in  any  advanced  stage  of  disease.  The  subject  of  a  pronounced  mental  exal- 
tation has  a  passion  for  intellectual  laboi',  accompanied  by  a  corresponding 
power  of  accomplishment.  It  is  no  longer  an  effort  to  fix  the  attention  upon 
an  intricate  subject  for  successive  hours.  The  sense  of  fatigue  is  lost,  and  the 
brain  works  on  without  pain,  the  quality  as  well  as  the  quantity  of  the  result 
being  beyond  that  which  the  individual  in  his  normal  condition  can  produce. 
This  state  of  mental  exhilaration  sometimes  comes  on  during  protracted 
mental  labor.  It  is  probably  always  associated  with  hyperseraia  of  the 
brain-cortex,  and  is  usually  accompanied  by  pronounced  insomnia.  It  is  a 
very  dangerous  condition,  and  should  be  the  signal  for  immediate  cessation 
of  mental  effort  and  for  medical  treatment.  It  is  sometimes  developed  with- 
out obvious  cause  as  a  prodrome  of  severe  mental  disease.  Thus,  I  have  seen 
it  precede  a  fatal  outbreak  of  acute  phrenitis,  and  it  may  usher  in  paretic 
dementia. 

If  one  or  more  of  the  mental  functions  are  excited  entirely  beyond  the 
control  of  the  will  and  judgment  becomes  impossible,  a  mental  condition  is 
produced  which  in  its  most  severe  acute  form  is  sometimes  spoken  of  as 
delirium,  and  in  its  milder  or  more  chronic  forms  as  insanitv. 

Failure  of  the  mental  powers  is  a  very  common  result  of  functional  and 
organic  brain  disease.  When  complete  it  constitutes  the  condition  known  as 
dementia. 

It  is  often  of  vital  importance  to  recognize  the  dawnings  of  mental  failure. 
The  failure  usually  manifests  itself  first  in  loss  of  memory.  This  will  be 
sufficiently  discussed  later.  (See  page  loQQ.)  Next  to  memory  in  the  order 
of  implication,  and  sometimes  even  preceding  it,  is  the  power  of  fixing  the 
attention.  The  mind  of  man  naturally  wanders  from  subject  to  subject.  A 
continuous  thoughtful  application  depends  upon  the  exertion  of  the  inhibitive 
power  of  the  will  in  repressing  distracting  thoughts  and  shutting  out  new  per- 
ceptions. The  power  of  persistent  attention  to  one  subject  is  to  a  great  extent 
ac(piired  by  training.  Its  exercise  is  a  large  feature  in  all  severe  intellectual 
work.  Consequently,  when  the  brain  is  exhausted  not  only  do  the  reasoning 
faculties  labor  with  difficulty,  but  increased  effort  is  required  from  the  weak- 
ened will  to  maintain  the  necessary  fixity  of  attention.  Mental  toil  becomes, 
therefore,  most  irksome,  as  is  recognized  by  the  common  expression  of  sufferers 
that  ''  work  is  becoming  more  and  more  of  an  effort."  Failure  of  memorv 
and  failure  of  the  power  of  fixing  the  attention  have  no  particular  diagnostic 


GENERAL    CONSIDEBATIONS.  533 

import.  When  they  coexist  and  are  associated  with  any  other  evidences  of 
mental  derangement  they  indicate  a  serious  disease  of  the  brain  itself.  The 
loss  of  the  power  of  fixing  the  attention,  however,  when  it  exists  alone,  nsu- 
ally  depends  upon  simple  cerebral  asthenia — a  condition  in  which  there  may 
also  be  some  loss  of  memory. 

A  symptom  which  may  dcjiend  upon  either  mental  excitement  or  loss  of 
mental  power  is  incoherence.  An  incoherence  due  to  a  heightened  but  irregu- 
lar cerebral  activity  results  from  the  excessive  rapidity  of  the  intellectual  acts, 
as  well  as  from  their  lack  of  connected  sequences.  Before  one  idea  is  fully 
translated  into  words  another  rushes  into  expression,  and  a  hopeless  confusion 
•of  talk  results.  The  ideas  tumble  out  as  it  were  over  one  another.  Incohe- 
rence from  lack  of  mental  power,  on  the  other  hand,  arises  either  from  the  ina- 
bility to  complete  the  mental  act  or  from  the  lack  of  the  power  of  translating  it 
into  suitable  words.  In  typical  cases  there  is  little  difficulty  in  distinguishing 
between  these  varieties,  which  it  is  allowable  to  call  respectively  active  and 
passive  incoherence.  The  rapid  utterances  of  the  raving  maniac  usually  show 
most  plainly  that  his  mind  is  pouring  out  broken  hints  of  an  infinite  series  of 
jostling  ideas ;  whilst  the  slow,  confused,  disconnected,  hesitating  words  of  the 
<lement  no  less  unmistakably  portray  his  inability  fully  to  conceive  an  idea 
and  embody  it  in  words.  There  are,  however,  many  cases  of  disease  in  which 
mental  excitement  coexists  with  failing  power,  and  in  which,  therefore,  the 
incoherence  is  of  mixed  type. 

Besides  the  symptoms  of  mental  aberration  connected  with  the  intellectual 
and  emotional  fticulties  already  spoken  of,  there  are  certain  specific  manifesta- 
tions— chiefly,  although  not  altogether,  dependent  upon  disorder  of  the  purely 
intellectual  faculties — which  need  careful  consideration.  Closely  connected — 
indeed,  in  large  j)art  due  to  disorder  of  the  perceptive  faculties — are  halluci- 
nations and  illusions. 

An  hallucination  is  the  perception  by  any  of  the  senses  of  an  object  which 
lias  no  existence.  It  is  the  conscious  recognition  of  a  sensation  of  sight,  hear- 
ing, feeling,  taste,  or  smell  which  is  not  due  to  any  impulse  received  by  the 
perceptive  apparatus  from  without,  but  arises  within  the  perceptive  apparatus 
itself:  in  other  words,  an  hallucination  is  a  subjective  sensation,  which  assumes 
the  definite  attributes  of  an  objective  sensation.  It  is  commonly  simple — i.  e. 
'Connected  with  a  single  sense.  Thus,  the  vision  is  usually  seen,  not  seen  and 
felt.  The  false  voice  is  heard,  the  mysterious  presence  is  felt,  but  the  presence 
and  the  voice  usually  do  not  coexist.  In  the  order  of  their  frequency  of  impli- 
■cation  the  senses  may  be  enumerated  as  follows  :  sight,  hearing,  touch,  smell, 
taste.  The  particular  characters  of  the  perceived  object  vary  indefinitely,  and 
involve  the  whole  range  of  perceptions.  Every  variety  of  color  and  form,  of 
sound  and  odor,  of  feeling  and  taste,  may  be  perceived. 

In  some  cases,  as  in  mirage,  a  false  perception  may  amount  almost  to  an 
hallucination  ;  that  is,  an  impulse  from  without  may  give  rise  to  such  a  dis- 
torted, misleading  conscious  perception  that  the  person  really  sees  or  feels  or 
hears  that  which  has  no  existence.     A  distorted  sensation — or,  in  other  words, 


534  MENTAL    DJSEAkiE^. 

the  perception  (»{'  an  ohject  in  characters  wliich  it  does  not  possess — is  fre- 
quently spoken  of  as  an  il/uslon.  In  nature  there  is  no  sharp  line  between 
illusions  and  sliirht  distortions  of  the  perception  of  objects,  or  between  illusions 
and  hallucinations.  An  hallucination  may  be  caused  by  an  external  stimulus 
so  slight  tliat  it  cannot  be  discovered,  but  it  may  arise  entirely  from  within 
the  nervous  system. 

An  hallucination  has  no  definite  diagnostic  import.  It  may  come  from 
exhaustion  of  the  nervous  system,  especially  when  there  is  at  the  same  time 
an  intense  desire.  Thus,  the  wife,  worn  out  with  long  watching  and  grief^ 
sees  in  obedience  to  her  yearnings  the  living  form  of  her  dead  husband.  The 
monk,  exhausted  by  long  prayer  and  fasting,  if  consumed  by  ardent  devotion^ 
is  comforted  by  saints  or  angels,  or,  if  he  be  tormented  by  suppressed  sexual 
desires,  is  haunted  by  troops  of  tempting  devils  or  voluptuous  sirens.  The 
person  perishing  with  thirst  sees  or  hears  cool  springs,  babbling  brooks,  or 
])lashing  fountains;  gorgeous  feasts  float  before  the  vision  of  the  starving;  and 
the  shipwrecked  mariner  is  tantalized  by  rescuing  barks. 

Hallucinations  may  be  the  result  of  the  immediate  action  of  a  poison,  as  in 
the  beatific  visions  of  the  hasheesh-eater,  or  may  be  the  outcome  of  the  pecu- 
liar nervous  state  which  follows  the  abuse  of  narcotic  stimuli,  as  in  delirium 
tremens.  Conditions  of  the  nervous  centres  at  present  inexplicable  may  call 
hallucinations  into  being,  as  in  hysteria.  More  rarely  the  hallucination  is  the 
result  of  an  organic  brain  disease,  when  its  nature  is  almost  invariably  pointed 
out  by  coexisting  symptoms,  such  as  epileptic  paroxysms  or  local  palsy.  The 
structural  alteration  in  such  cases  is  commonly  in  the  nerve-tract  especially 
connected  with  the  affected  sense. 

An  hallucination  does  not  necessarily  depend  u])on  or  prove  the  existence 
of  intellectual  unsoundness.  It  is,  however,  very  apt  to  be  associated  with 
such  unsoundness,  because  the  condition  of  the  sensory  brain  tract  which  pro- 
duces it  is  aj)t  to  accompany  a  similar  condition  of  the  higher  or  intellectual 
centres.  Moreover,  it  often  affords  us  a  means  of  testing  the  condition  of  the 
brain-centres.  If  the  judgment  fails  to  correct  the  testimony  of  the  disordered 
s(!nse  by  that  derived  from  other  senses,  the  subject  is  of  unsound  mind. 
When,  for  example,  the  individual  believes  that  the  vision  that  he  sees  or  the 
voice  that  he  hears  really  exists,  then  is  his  judgment  dethroned.  It  will  be 
readily  seen  that  in  such  a  case  it  is  not  the  seeino;  of  the  vision,  but  the  loss 
of  the  power  of  weighing  evidence,  that  is  the  proof  of  the  intellectual  degra- 
dation. As  will  become  very  apparent  during  the  discussion  of  delusions,  the 
hallucination  in  the  case  just  imagined  has  given  rise  to  a  delusion. 

An  hallucination  which  is  not  very  vivid  is  sometimes  spoken  of  as  apseudo- 
liallucination.  Certain  authorities  attenij>t  to  make  a  sharp  separation  between 
pscudo  and  true  hallucinations.  It  is  affirmed  that  the  pseudo-hallucination 
always  remains  to  the  individual  who  has  it  a  subjective  phenomenon,  whilst 
the  genuine  hallucination  aj)pears  to  the  individual  as  reality  itself.  It  is  clear 
that  the  pseudo-hallucination  of  some  writers  is  simply  an  hallucination  which 
is  recognized  by  the  intellect  as  a  subjective  phenomenon,  and  therefore  does 


GENERAL    COySIDKRA  TIONS.  535 

not  give  rise  to  an  insane  delusion.  The  true  liallueination  of  such  writers 
is  a  eombination  of  an  hallucination  Mith  an  insane  delusion.  In  nature  there 
seems  to  be  every  possible  gradation  between  the  faintest  delusion  or  hallucina- 
tion and  the  illusion  or  hallucination  which  is  completely  believed  in  by  the 
individual  and  most  completely  dominates  him. 

The  word  delusion  may  be  defined  to  be  a  false  belief,  but  as  it  is  used  by 
alienists  the  term  means  something  more  than  this.  By  Spitzka  the  insane 
delusion  is  said  to  be  "  a  faulty  belief  out  of  which  the  subject  cannot  be  rea- 
soned by  adequate  methods  for  the  time  being."  The  objection  to  this  defini- 
tion is  that  there  are  many  faulty  or  false  beliefs  held  by  perfectly  sane  persons 
out  of  which  such  jiersons  cannot  be  reasoned,  but  which  are  not  insane  delu- 
sions. Thus,  either  the  Christian  or  the  Mussulman,  under  such  definition,  is 
the  victim  of  an  insane  delusion.  To  meet  the  necessities  of  the  case  the  defini- 
tion should  be  modified  so  as  to  read,  "A  faulty  belief  concerning  a  subject 
capable  of  physical  demonstration,  out  of  which  the  person  cannot  be  reasoned 
by  adequate  methods  for  the  time  being." 

The  parallelism  between  a  delusion  and  an  hallucination  is  very  close.  A 
delusion  is  a  false  belief;  an  hallucination  is  a  false  perception.  The  delu- 
sion becomes  an  insane  one  only  when  the  false  belief  cannot  be  dissipated  by 
absolute  proof  of  its  incorrectness.  The  hallucination  becomes  an  insane  one 
only  when  the  false  ])crception  cannot  be  corrected  by  the  judgment  through 
the  other  senses.  In  either  case  the  essence  of  the  insane  mental  state  is  loss 
of  power  to  receive  and  weigh  adequate  evidence. 

Thus,  John  Smith  hears  voices  where  there  are  none :  he  is  insane  only 
when  he  is  unable  to  correct  the  evidence  received  through  the  sense  of  hearing 
by  that  received  through  the  senses  of  sight  and  feeling.  If  ,he  persistently 
l)elieves  that  persons  s])eak  to  him,  although  he  cannot  see  or  touch  them,  his 
judgment  is  in  abeyance.  On  the  other  hand,  John  Jones  believes  that  a  cer- 
tain barn  exists  upon  a  certain  field  where  there  is  no  barn.  Under  these 
circtmistances  he  has  a  delusion,  a  belief  which  has  grown  up  in  his  mind 
from  some  cause  unknown.  Now,  if,  when  taken  to  the  field,  he  is  incapable 
of  receiving  the  evidence  of  his  senses  and  persists  in  his  belief  that  the  barn 
is  there,  he  is  insane;  but  if  he  receives  the  evidence  of  his  senses  and  per- 
ceives that  the  barn  does  not  exist,  he  is  not  insane.  In  case  of  insane  hal- 
lucinations or  delusions  the  truth  or  falsity  of  the  vision  or  of  the  belief  is  not 
essential.  The  essential  thiny;  is  the  condition  of  the  mind  of  the  individual 
— a  condition  which  prevents  it  from  receiving  evidence.  Hence  an  insane 
belief  mav  be  true  althou*;!!   insanely  hchl. 

In  the  sup])osititious  case  given  above  assuredly  the  mental  state  ol"  the 
individual  is  in  no  wise  dej)endent  u])(»n  the  absence  of  tlie  barn,  although 
such  absence  renders  a  test  of  the  subject's  mental  condition  possible.  'J'he 
distinction  just  drawn  may  seem  iiiiiiMj)ort;iiit  and  so  trite  as  to  Itc  unworthy 
of  discussion,  but  the  failure  to  understand  it  has  Ixcii  one  cause,  in  my  ('xj)c- 
riencre,  of  tiie  inability  on  the  ]>art  of  learned  lawyers  to  comprehend  the 
subject   of    insanity. 


536  MENTAL    DISEASES. 

Not  long  ago,  after  due  process  of  law,  an  insane  man  by  the  name  of 
Taylor  was  hung  in  Phila(lel])hia  for  the  unprovoked  murder  of  a  prison- 
warden.  It  was  in  evidence  that  the  mail  believed  that  all  the  attendants 
of  the  prison  were  Catholics,  and  were  "down  on"  him  because  he  was  a 
Protestant,  and  were  destroying  him.  The  ])rosecuting  attorney  asked,  "  Sup- 
])osing  it  were  proved  that  the  prison  attendants  were  Catholics,  would  it  not 
have  to  be  acknowledo;ed  that  the  man's  belief  was  correct,  and  that  he  was 
not  insane?"  Apparently  neither  lawyer  nor  judge  could  be  made  to  under- 
stand that  the  falsity  or  thfe  truth  of  the  prisoner's  belief  in  the  Catholicism 
of  the  attendants  had  little  to  do  with  the  question  of  his  insanity.  It  was 
proved  that  he  had  other  delusions  of  persecution,  and  his  having  adopted  a 
belief  in  regard  to  the  Catholicism  of  his  attendants  which  was  in  accord  with 
such  delusions,  without  any  evidence  of  their  alleged  Catholicism,  and  having 
reasoned  insanely  upon  the  subject  and  acted  in  ac(X)rdance  with  conclusions  so 
reached,  showed  that  his  action  rested  upon  mental  unsoundness.  Surely  the 
^'■Because  I  am  a  Protestant,  therefore  they  are  destroying  me,"  ought  to  have 
made  the  mental  condition  of  the  prisoner  clear.  In  the  language  of  Spitzka, 
*'  Repeatedly  does  it  occur  in  the  alienist's  experience  that  the  facts  of  a  case 
and  the  delusion  happen  to  correspond."  This  is  well  illustrated  in  a  case 
reported  by  him.  An  artist's  model  asserted  that  he  was  the  finest-built  man 
in  the  United  States.  He  really  had  a  magnificent  figure,  but  his  announce- 
ment was,  notwithstanding,  that  of  a  paretic  dement,  for  inquiry  elicited  the 
statement  that  the  "  girls  looked  at  him  because  he  had  a  pecidiar  expression 
in  his  eyes  which  they  fancied,"  and  he  revealed  other  unmistakable  evidence 
of  general  paralysis. 

An  insane  bplief  or  delusion  may  rest  upon  an  hallucination,  may  be  built 
upon  a  foundation  of  disordered  sensation,  may  spring  from  the  most  trivial 
circumstances,  or  may,  so  far  as  can  be  judged,  be  self-engendered  in  the  mind. 
Thus,  the  voice  that  is  heard  as  an  hallucination  gives  rise  to  the  delusion  of 
an  ever-present  persecutor  ;  a  persistent  distress  in  the  abdomen  to  a  delusion 
of  j)regnancy  or  that  the  bowels  are  dropping  out,  etc.  The  following  case 
from  my  notebook  illustrates  very  forcibly  the  curious  way  in  which  a  delu- 
sion develops  in  the  mind  without  the  slightest  foundation  in  verity  :  A  man 
after  a  malarial  fever  began  to  have  suspicions  in  regard  to  the  chastity  of  his 
wife.  For  a  time  he  kept  these  to  himself,  but  finally  he  accused  her  of  infi- 
delity. After  this  had  continued  for  some  weeks  he  presented  himself  with 
his  wife  at  my  clinic,  saying  to  me,  "  I  think  my  wife  goes  with  other  men  : 
she  thinks  I  am  crazv.  I  am  uncertain  whether  she  or  I  am  rio-ht."  On 
being  questioned,  he  stated  that  he  first  noticed  her  looking  behind  her,  as 
though  she  were  looking  for  some  one,  when  they  walked  together;  that  he 
afterward  saw  a  handkerchief  lying  on  the  bureau  in  her  room,  just  as  she 
would  have  left  it  if  she  had  been  flirtino;  with  some  one  out  of  the  window, 
and  that  when  he  saw  a  chair  by  the  window  of  her  room  and  a  man  at  the 
<-orner  of  the  street  he  was  convinced  that  his  suspicions  were  correct :  in  this 
lie  was  corroborated  by  finding  three  dollars  in  a  trunk,  which  he  believed  his 


GENERAL    COXSI DERATIONS.  537 

■wife  had  received  '*  for  evil  courses,"  although  she  had  declared  that  he  him- 
self had  given  it  to  her.  He  further  stated  that  he  watciied  her  eyes.  In  a 
very  eager,  tremulous  manner  he  said,  "  I  got  a  lamp,  and  when  J  found  her 
•eyes  were  dark  beneath,  I  told  her  there  was  something  wrong  with  her,  and 
then  she  began  to  think  there  was  something  wrong  with  me.  1  firmly  believed 
she  was  going  with  other  men."  Tiie  man  had  an  inherited  tendency  toward 
insanity,  and  had  lost  much  sleep.  When  his  whole  case  w^as  thoroughlv 
explained  to  him,  he  said  that  he  "  now  understood  it,  and  was  glad  to  hear 
it,  and  that  it  gave  him  power  to  brace  himself  against  the  notion,"  ending 
with  the  assertion  that  he  believed  that  ''  he  had  a  good  woman."  In  reply  to 
a  question,  he  said,  "  I  do  not  think  there  is  danger  of  ray  hurting  mv  wife, 
but  these  things  come  on  me  so  that  I  cannot  control  myself  at  times,  and  I 
am  willing  to  go  to  an  asylum  if  it  is  thought  to  be  right." 

The  relation  between  the  emotional  state  of  an  insane  man  and  his  delu- 
sions is  very  close.  Expansive  or  happy  delusions  accompany  emotional 
exaltation,  while  horrible  or  sorrowful  delusions  go  hand  in  hand  with  depres- 
sive emotions.  Thus,  the  melancholic  woman  is  oppressed  with  the  belief  that 
she  is  hopelessly  damned,  that  her  luisband  is  unfaithful,  or  that  she  is  preg- 
nant with  devils ;  whilst  the  maniac,  overflowing  with  animal  spirits,  is  a 
proj)het  sent  of  God,  is  owner  of  uncounted  millions,  or  mayhap  is  about  to 
become  the  mother  of  the  Messiah.  The  emotional  state  and  the  delusions 
constantly  react  upon  one  another.  Some  alienists  believe  that  the  character 
of  the  delusion  is  directly  dependent  upon  the  dominant  emotion. 

The  nature  of  delusions  varies  so  indefinitely  as  to  render  any  attempt  at  a 
thorough  classification  futile.  There  are,  however,  certain  classes  of  delusions 
which  are  so  frequently  met  Avith  and  so  characteristic  as  to  require  especial 
study.  The  most  important  of  these  are — 1.  Expansive  Delusions;  2. 
Hypochondriacal  Delusions ;   3.   Delusions  of  Persecution. 

Expansive  Delusions  usually  concern  the  ])ersonality  of  the  individual  who 
has  them,  either  as  to  his  prowess,  his  mental  or  physical  attainments,  his  pos- 
sessions, or  his  future  prospects.  The  jiatient  boasts  that  he  is  the  strongest 
man  in  the  world,  asserts  that  his  mental  powers  are  immense,  or  that  he  is  a 
king  or  other  notability,  or  more  commonly  talks  of  his  millions  of  money, 
his  gold-mines,  his  farms  of  unlimited  extent,  his  vast  stables  full  of  uinnun- 
bered  horses  of  the  choicest  breeds,  liis  far-reaching  and  gigantic  business 
schemes,  etc.  This  condition  constitutes  the  delire  de  (jrandew,  and,  whilst  in 
the  majority  of  cases  it  depends  upon  the  existence  of  general  paralysis,  it  nuiy 
be  i)resent  in  many  forms  of  mental  disease.  I  have  seen  it  very  pronounced 
in  cerebral  syphilis,  and  have  watched  th(>  millions  of  dollars  possessed  by  the 
subject  shrink  to  thousands,  and  the  thousands  to  hinulreds,  as  the  brain  lesions 
grew  less  under  the  administration  of  mercury.  Then  ev(Mi  the  luuidreds  dis- 
aj)|)cared,  and  his  own  j)overty  was  confessed  ;  but  the  assertion  still  remained 
that  "  his  uncle  was  worth  a  million,"  until  at  last  this  too  vanished  in  the 
recognition   of  the  desolate  truth. 

II ijpochondriacal  JJelusions  relate  t(j  disease  of  the  person  of  tlie  patient, 


538  MENTAL    DISEASES. 

and  are  usually,  but  not  always,  associated  with  a  depressive  emotional  state. 
They  sometimes  rest  upon  a  substratimi  of  ill-feeling,  or  even  of  actual  disease,. 
in  the  part  alleged  to  be  hopelessly  affected.  They  are  often  obviously  absurd, 
as  that  the  legs  are  made  of  glass.  Of  all  forms  of  delusion,  this  is  the  one 
in  which  the  gradations  between  the  sane  and  the  insane  belief  are  most  sub- 
tile. Every  step  can  be  found  between  the  slightest  exaggeration  of  symptoms 
and  the  hvpochondriacal  foundationless  belief.  Unless  a  hypochondriacal  delu- 
sion is  upon  its  face  absurd,  the  physician  must  be  very  careful  in  basing  upon 
it  an  opinion  that  the  subject  of  it  is  irresponsible,  since  many  invalids  are- 
hypochondriacs  and  have  exaggerated  beliefs  bordering  closely  upon  delu- 
sions, but  are,  nevertheless,  of  sufficiently  sound  mind  for  the  performance  of 
the  ordinary  duties  of  life. 

Delusions  of  Persecution  are  not  always  associated  with  a  pronounced 
depressive  emotional  condition.  They  are  always  the  source  of  great  annoy- 
ance and  distress  to  the  subject,  and  are  usually  associated  with  hallucinations 
which  I  think  are  most  apt  to  be  connected  with  the  sense  of  hearing.  Very 
commonly  obscene,  reproachfnl,  or  threatening  voices  are  heard  at  all  times 
and  in  all  places.  Usually  the  delusion  of  persecution  does  not  attach  itself  in 
the  mind  of  its  victim  to  one  person,  but  to  classes  of  people  or  to  unseen 
spirits.  Sometimes,  however,  the  delusion  does  affix  itself  to  one  individual,, 
as  in  a  recent  case  in  which  a  woman  travelled  across  the  continent  of  America 
to  kill  a  doctor  who  she  believed  was  placing  a  spell  upon  her.  Of  all  the 
quiet  classes  of  the  insane,  those  who  have  delusions  of  persecution  are  the 
most  dangerous.  They  are  impelled  by  motives  of  revenge  and  of  fear  to  kill 
those  who  are  persecuting  them.  This  is  especially  the  case  when  the  delusion 
attaches  itself  to  one  individual ;  but  even  voices  in  the  air  may  lead  to  sudden 
violent  assaults  upon  bystanders  who  are  for  the  moment  thought  to  be  the 
source  of  the  words.  Moreover,  the  lunatic  may  at  any  time  fix  in  his  mind 
upon  any  acquaintance  or  notable  person  as  the  origin  of  his  persecution  and 
make  his  plans  in  accordance. 

A  very  important  division  of  delusions  is  into  systematized  and  unsystem- 
atized. A  si/steinatized  delusion  is  one  concerning  which  the  subject  reasons, 
and  which  he  defends  more  or  less  logically.  Any  character  of  delusion  may 
be  systematized.  If  a  lunatic  asserts  that  he  is  worth  a  million  of  dollars,  and 
simply  sticks  to  his  belief  when  it  is  denied,  he  has  an  unsystematized  delusion 
of  grandeur;  but  if  he  should  attempt  to  defend  his  delusion  by  describing 
how  he  had  inherited  his  wealth  or  how  he  had  acquired  it  through  investments, 
or  business  ventures,  his  delusion  would  be  systematized.  Again,  a  person  suf- 
fering from  melancholia  believes  that  his  soul  is  lost.  If,  when  opposed,  he 
simply  reavows  his  belief  and  assigns  no  reasons  for  it,  his  delusion  is  unsys- 
tematized ;  but  if  he  says  he  is  lost  because  he  has  committed  the  unpardon- 
able sin,  quotes  Scripture  to  show  that  such  a  sin  warrants  his  doom,  and  per- 
haps tells  why  and  when  he  sinned,  his  delusion  is  systematized. 

Great  diagnostic  value  has  been  attached  by  some  recent  writers  to  the  dis- 
tinction between  systematized  and  unsysteinatized  delusions,  and  much  has  been 


GEXEIiAL    (:Oy;SJlJKRATIONS.  5o*J 

predicated  upon  it  in  the  classification  of  insanities.  According  to  my  experi- 
ence, however,  in  nature  every  gradation  is  to  be  found  between  the  most  thor- 
ouffhlv  systematized  dehision  and  that  which  is  most  completely  isolated.  I 
have  seen  various  cases  in  which  it  was  doubtful  whether  the  delusion  shotdd 
be  classed  as  systematized  or  unsystematized  ;  and,  wiiilst  I  acknowledg-e  that 
in  typical  paranoiacs  the  delusions  are  systematized  and  in  typical  general  in- 
sanities they  are  unsystematized,  I  am  of  the  opinion  that  in  this  character,  as 
in  others,  the  two  groups  of  general  and  partial  insanities  pass  in  nature  insen- 
sibly into  each  other. 

There  are  certain  conceptions  or  general  ideas  whi(;h  may  arise  in  the  brain 
of  a  person,  and  to  a  greater  or  less  degree  dominate  his  actions,  although  the 
reason  may  not  be  unsettled  and  the  falsity  of  the  conception  may  be  recognized 
by  the  individual  whom  it  controls.  Such  a  phenomenon  is  known  as  an  Im- 
pcroiive  Conception,  and  differs  from  a  delusion  in  that  its  falsity  is  recognized, 
although  the  individual  is  powerless  to  withstand  its  influence.  Closely  allied 
to  the  imperative  conception  is  the  Morbid  Impulse.  Some  alienists,  indeed, 
teach  that  the  imperative  conception  gives  rise  to  the  morbid  impulse.  In  cer- 
tain cases  this  undoubtedly  happens,  as  when  the  imperative  conception  of  per- 
sonal defilement  gives  origin  to  the  impulse  of  escaping  from  that  which  defiles ; 
but  a  morbid  imj)ulse  may  arise  without  any  discoverable  imperative  conception. 
Thus,  I  long  had  under  my  care  a  man  in  whose  family  insanity  was  distinctly 
hereditary,  but  in  whom  the  only  symptom  that  I  could  find  was  an  impulse  to 
assault  bystanders — an  impulse  a])parently  born  of  no  reason,  although  felt 
with  such  urgency  as  to  fill  the  patient  with  a  terror  of  himself.  Once,  upon 
returninw;  home,  I  found  this  man  sittino;  in  my  office  terribly  excited,  and 
greeting  me  with,  "  Doctor,  doctor,  I  nearly  did  it !  I  nearly  did  it !"  It 
appeared  that  he  had  spent  forty-eight  hours  without  intermission  in  a  vortex 
of  political  excitement,  and  suddenly  the  inijndse  to  kill  had  come  on  him  with 
such  power  that  only  by  fleeing  to  my  office  was  he  able  to  save  himself.  The 
impulse  to  throw  one's  self  from  a  precipice,  caused  by  standing  on  its  brink, 
is  a  familiar  instance  of  a  mild  morbid  impulse  without  an  apparent  foundation 
of  an  imperative  conception  ;  whilst  the  reasonless  dread  which  many  pei-sons 
have  of  a  snake,  toad,  cockroach,  or  other  harmless  creature  probably  depends 
upon  an  incipient  imperative  conception  of  personal  defilement. 

Tiie  act  which  results  from  a  morbid  impulse  is  sometimes  spoken  of  as  an 
Imperative  Act.  An  imperative  conception  is  viewed  by  some  alienists  as  an 
''■  undeveloped  delusion."  It  is,  however,  not  a  proof  of  general  mental 
unsoundness,  but  in  some  cases  finally  the  reason  of  the  patient  fails  to 
recognize  the  untruthfulness  of  the  imperatiye  conce])tion,  which  conception 
thereby  l)ecomes  converted  into  a  delusion,  precisely  as  an  hallucination  may 
give  rise  to  a  delusion. 

A  vciy  important  and  conmion  iiuperative  conception  is  a  morbid  fear. 
This  may  take  almost  any  form,  and  may  be  simply  au  exaggeration  of  a 
noiiiial  feeling  or  may  arise  de  novo.  Thii-^,  in  some  persons  the  fear  of  a 
thunderstorm   is  so  violent  as  to  destroy  for  the  time  being  all  rationality;  in 


540  MENTAL    DISEASES. 

others  the  natural  dislike  for  filth  is  increased  until  it  dominates  every  action 
of  life.  On  the  other  hand,  the  horror  of  walking  in  an  open  place,  which 
is  sometimes  so  overwhelming,  seems  scarcely  to  be  based  upon  any  natural 
feeling.  To  many  of  these  morbid  fears  names  have  been  given  by  systematic 
writers.  The  fears,  however,  vary  so  in  their  detail  that  it  is  not  possible  to 
express  them  accurately  and  fully  by  any  system  of  nomenclature.  A  few  of 
these  names  may  be  cited,  as  representing  the  more  characteristic  forms  of 
morbid  fear.  The  following  list,  taken  from  Dr.  Beard,  portrays  very  well 
the  absurdities  of  nomenclature  : 

Astraphobia,  fear  of  lightning ;  Topophobia,  fear  of  places  (a  generic 
term,  with  these  subdivisions  :  Agoraphobia,  fear  of  open  places ;  Claustro- 
phobia, fear  of  narrow,  closed  places) ;  Anthrophobia,  fear  of  man — a  generic 
term,  including  fear  of  society ;  Gynsephobia,  fear  of  woman  ;  Monophobia, 
fear  of  being  alone;  Pathophobia,  fear  of  disease — usually  called  hypochon- 
driasis ;  Pantaphobia,  fear  of  everything ;  Phobophobia,  fear  of  being  afraid ; 
Mysophobia,  fear  of  contamination. 

As  illustrating  imperative  conceptions  a  few  cases  from  my  own  experience 
may  be  cited.  A  very  strong  shoemaker,  past  middle  life,  was  oppressed  with 
the  idea  that  he  could  not  walk  unless  he  had  some  covering  over  his  head. 
On  a  stormy  day  the  natural  cloud-canopy  sufficed,  and  on  a  clear  day  an 
umbrella  carried  over  his  head  gave  a  measure  of  relief,  so  that  he  was  able 
to  command  his  movements.  He  could  walk  in  a  tliick  wood,  but,  as  he 
liimself  said,  if  ten  feet  of  clear  sky  intervened  between  the  wood  and  a 
spring,  he  would  die  of  thirst  before  he  could  cross  over.  No  other  symp- 
tom of  physical  or  mental  ailment  could  be  detected. 

A  lady  had  a  dread  of  personal  defilement.  Hundreds  of  times  daily  she 
washed  her  hands,  without  avail ;  bank-notes  fresh  from  the  press  were  the  only 
money  she  would  use;  a  door-knob  she  would  never  touch,  but  would  remain 
in  the  room  until  some  one  opened  the  door;  in  putting  on  her  clothes  only 
the  inside  of  each  piece  was  touched  by  her  fingers,  and  this  as  daintily  as  pos- 
sible. Without  entering  into  further  details,  suffice  it  to  state  that  her  whole 
life  was  arranged  in  order  to  avoid  as  much  as  possible  contact  with  any 
person  or  thing.  On  my  asking  her  to  shake  hands  her  embarrassment  was 
extreme :  though  naturally  polite  and  feeling  under  some  obligation  to  me, 
.she  was  nevertheless  entirely  dominated  by  her  imperative  conception.  Finally 
she  said,  ''  Dear  doctor,  don't  ask  me :  you  know  you  touch  so  many  people." 

A  gentleman  entirely  rational,  able  to  manage  his  business  affiiirs  well  and 
to  converse  on  all  subjects,  was  completely  ruled  by  imperative  conceptions 
and  morbid  impulses,  the  connection  and  the  independence  of  which  are  well 
illustrated  by  his  case.  Thus,  for  many  years  he  had  an  impulse  continually 
to  rub  his  arms  against  his  sides,  and  this  he  did  incessantly  until  coat  after 
coat  was  rubbed  into  holes.  No  morbid  conception  could  be  found  underly- 
ing this  or  some  of  the  other  impulses  which  he  had.  Nevertheless,  he  did 
have  imperative  conceptions  with  outgrowing  secondary  impulses.  For  many 
months  he  was  markedly  mysophobic.     Tiien  he  had  the  conception  that  he 


GENERAL    COXSIDERA  TIONS.  541 

must  lay  things  down  straight  and  could  not  do  it.  Most  of  his  waking 
moments  were  at  this  time  spent  in  putting  down  and  arranging.  AVhen 
he  placed  a  book  on  the  table,  over  and  over  and  over  again  he  would  lift 
it  up,  straighten  it,  pick  it  up  and  relay  it,  etc.  Often  at  night  he  would 
be  two  or  three  hours  getting  away  from  his  coat,  which  he  was  perpetually 
arranging  upon  the  chair  on  which  he  had  laid  it.  There  was  no  delusion, 
and  on  my  asking  the  man  why  he  yielded  to  the  impulse,  he  said,  "I  can 
resist  it  for  a  while,  but  after  a  time  the  same  overpowering  sensation  comes 
as  when  I  hold  by  breath,  and  I  must  do  it.  I  have  found  that  if  I  say  very 
fast,  '  It  is  straight,  it  is  straight,'  over  and  over  again,  at  the  same  time  crack- 
ing my  fingers  briskly  by  shaking  my  hand,  the  impulse  often  suddenly  van- 
ishes, with  immediate  relief'*' 

The  end  of  this  unfortunate  victim  of  disordered  nerve-centres  was  very 
tragic.  Bv  erreat  care  and  effort  he  had  succeeded  in  concealing  from  the  gene- 
ral  public  his  mental  weakness,  and  was  engaged  in  business  enterprises  of  large 
magnitude.  In  the  course  of  one  of  these  it  so  happened  that  he  became 
involved  in  a  lawsuit  which  finally  necessitated  his  going  upon  the  witness- 
stand.  The  newspapers  of  the  morning  of  the  day  upon  which  his  testimony 
was  to  have  been  taken  announced  his  sudden  and  unaccountable  suicide. 
Excessively  sensitive  and  proud,  when  he  found  himself  in  such  a  position 
that  he  must  reveal  to  the  public  his  extraordinary  peculiarity,  he  preferred 
to  such  exposure  death  by  his  own  hands. 

The  relation  of  imperative  conceptions  and  morbid  impulses  to  insanity  is 
a  matter  of  great  theoretical  and  practical  interest.  They  are  undoubtedly  fre- 
quent in  the  insane,  and  usually  careful  examination  of  a  case  in  which  they 
are  present  will  reveal  distinct  symptoms  of  alienation.  They  may,  however^ 
exist  in  persons  whose  intellectual  actions  are  in  other  respects  entirely  nor- 
mal, and  in  whom  the  judgment  is  not  dominated  by  the  conception,  although 
the  conception  may  cause  him  to  ])erform  actions  which  are  against  his  judg- 
ment. To  himself  the  sane  subject  of  an  imperative  conception  seems  pos- 
sesse<l  by  a  demon  whom  he  must  obey. 

The  relation  of  morbid  conceptions  and  impulses  to  legal  responsibility  for 
acts  committed  involves  questions  of  great  practical  difficulty.  The  victim  of 
the  morbid  iminilse  cannot  properly  urge  such  impulses  as  excuses  unless  the 
deed  in  question  be  immediately  produced  by  them.  When  the  act  is  com- 
mitted because  the  actor  is  forced  to  do  it  by  a  morbid  impidse,  the  actor 
is,  of  course,  morally  blameless;  but  who  can  tell  whether  the  imj)ulse  was 
resisted  to  the  uttermost  ?  Moreover,  the  needs  of  society,  and  the  ease  with 
which  such  imi)ulses  could  be  alleged  or  counterfeited,  very  properly  cause  us 
to  pause  in  attempting  Vjy  them  to  excuse  a  criminal  act.  The  clearest  possible 
proof  should  be  required  that  the  impulse  was  really  morbid  and  irresistible. 

I>y  the  use  of  the  word  ''mania"  as  a  siidix  numerous  names  have  been 
formed  which  are  sometimes  incorrectly  used  as  denoting  the  morbid  impulse, 
although  thev  in  fact  are  only  correctly  ap|)licable  to  tlie  mental  state  miderly- 
intr  the  iiiijuil-c.      In  juirfniimii't  the  (uorbid  im|)ulse  is  to  set  fire  to  buildings; 


542  MENTAL    DISEASES. 

in  kleptomania,  to  steal ;  in  homicidal  mania,  to  kill ;  in  suicidal  mania,  to 
commit  suicide;  in  arithromania,  to  be  perpetually  making  calculations  or 
counting  in  abstract  numbers,  or  perhaps  reckoning  a  multitude  of  some 
supposititious  concrete  thing. 

The  so-called  "manias"  are  not,  however,  distinct  insanities  at  all:  most 
of  them  are  formed  of  reasoning  insanities ;  but  a  morbid  impulse  may  arise 
in  almost  any  form  of  insanity.  Again,  what  seems  a  morbid  impulse  is  often 
the  result  of  a  logical  deduction  from  false  premises  by  the  diseased  mind. 
Thus,  the  man  who,  not  believing  in  a  future  existence,  commits  suicide  because 
lie  is  suffering  from  the  unutterable  misery  of  melancholia,  is  logical  and  rea- 
sonable in  his  suicide,  and  does  not  kill  himself  through  any  morbid — i.  e. 
unreasoning — impulse.  Suicidal  and  homicidal  maniacs  are  simply  maniacs 
who  have  a  tendency  to  kill  themselves  or  others. 

Morbid  Desires  are  exaggerations  or  perversions  of  natural  appetites,  and 
are  chiefly  seen  in  regard  to  hunger  and  the  sexual  passion.  Mere  depravity 
and  wickedness  may  convert  man  into  a  monster  :  neither  cannibalism  nor  the 
lowest  sexual  degradation  is  necessarily  the  offspring  of  disease.  Nevertheless, 
disease  may  affect  the  appetite  for  food  or  for  sexual  congress,  as  it  does  other 
functions  of  the  nervous  system. 

In  mania,  in  paretic  dementia,  in  hysteria — indeed,  in  almost  any  form  of 
insanity  with  excitement  and  exaltation — the  sexual  passion  may  become  an 
all-devouring,  insatiable  lust.  In  the  female  this  condition  is  known  as 
nymphomania;  in  the  male,  as  satyriasis.  The  victim  of  it  talks  incessantly 
and  indecently  about  sexual  congress,  makes  furious  love  to  all  persons  of  the 
opposite  sex,  exposes  the  person,  etc.  Erotomania  is  a  very  frequent  condition 
in  which  there  is  the  appearance  but  not  the  reality  of  sexual  excitement.  The 
subject  of  it  conceives  a  strong  attachment  for  some  person  of  the  opposite  sex 
whom  perhaps  he  or  she  has  never  seen,  and  lives  in  an  attitude  of  a  perpetual 
worship.  Sometimes  the  object  is  in  public  life,  and  is  followed  from  place  to 
])lace  with  a  pertinacity  and  publicity  which  may  amount  to  actual  persecu- 
tion. Even  if  opportunity  offer,  the  erotomaniac  makes  no  effort  at  cohabita- 
tion. Satyriasis  leads  to  sexual  excess  and  to  rape.  Erotomania  is  a  platonic 
affection,  which  involves  the  higher  conceptive  sphere  rather  than  the  lower 
nerve-centres  and  leads  to  sexual  abstinence. 

Human  character  is  the  result  of  the  established  balance  between  the  will, 
the  intellectual  attributes,  and  the  emotional  forces  of  the  individual.  When 
any  of  the  correlated  factors  are  altered  there  must  be  a  corresponding  change 
in  character.  Character  is,  therefore,  always  seriously  implicated  in  mental 
affections.  Not  rarely  changes  in  the  intellectual  or  emotional  nature  so  sub- 
tile or  hidden  as  not  to  be  readily  perceived  register  themselves  with  astound- 
ing distinctness  on  the  dial-plate  of  character.  Hence  alterations  of  character 
are  of  the  weightiest  diagnostic  import.  They  may  be  the  first  evidences  of  a 
<leveloping  pure  insanity,  but  when  sudden  and  severe  they  usually  point 
toward  dementia  paralytica.  A  primary  sudden  criminal  outbreak  in  dementia 
]>aralytica  is  generally  sexual  in  its  direction.     Thus,  in  a  case  formerly  under 


GENERAL    ('OysiDKhWTIOXS.  543 

my  care  the  first  marked  disorderly  action  was  an  attenipt  to  rape  a  servant- 
girl.  After  this  it  was  discovered  that  very  large  and  foolish  jMirchases  had 
been  made  as  the  beginning  of  a  grand  business  scheme  entirely  ibreign  to  the 
<1aily  occupation  of  the  man.  An  estimable  citizen  goes  to  a  distant  city  and 
urtempts  to  turn  a  hotel  into  a  hawdy-house ;  another,  whilst  still  performing 
acceptably  the  duties  of  an  imjiortaut  public  office,  tries  to  seduce,  and,  this 
tailing,  to  rape,  his  own  daughter. 

In  dementia  paralytica,  as  in  the  pure  insanities,  the  moral  degradation 
may,  however,  run  in  other  than  sexual  channels.  The  temperate  man  sud- 
denly becomes  addicted  to  drink  ;  the  honest  man  all  at  once  apjiropriates 
large  sums  of  money,  which,  it  may  be,  he  spends  in  licentious  revels ;  he  who 
has  always  been  exceptionally  self-controlled  becomes  violently  passionate ;  the 
amiable,  loving  husband  and  father  changes  into  a  household  demon.  Careful 
examination  under  these  circumstances  will  usually  detect  other  symptoms  of 
the  coming  or  already-present  insanity. 

Before  entering  upon  the  discussion  of  the  classifications  of  insanity  the 
question  how  much  of  abnormal  mental  action  is  com])atil)le  with  sanity 
seems  naturally  to  present  itself.  Its  answer  involves  the  definition  of  the 
words  sanity  and  insanity,  and,  like  these  definitions,  probably  will  always  be 
imsatisfactorv.  Insanity  is  not  a  definite  disease,  but  an  abnormal  state,  vary- 
ing  indefinitely  in  its  intensity,  separated  by  no  tangible  line  from  sanity, 
arising  from  a  number  of  diverse  diseases,  and  terminating  in  most  various 
ways. 

Moreover,  the  manifestations  of  insanity  are  simply  alterations,  exaggera- 
tions, or  perversions  of  the  normal  faculties,  and  therefore  offer  nothing  that 
is  absolutely  new.  Emotional  depression  deepens  into  the  jirofoundest  melan- 
cholia, emotional  exaltation  lifts  itself  into  the  highest  mania,  by  a  gradation 
as  insensible  as  that  by  which  the  beach  slopes  into  the  deep  ocean  or  the 
mountain  rises  into  the  air  ;  and  who  shall  say  where  the  dividing-line  is 
between  the  state  in  which  the  man  is  master  of  the  mood  and  that  in  which 
the  mood  is  master  of  the  man  ?  The  insane  impidse  is  but  an  exaggeration  of 
that  which  bids  a  man  standing  on  the  verge  of  some  great  height  to  })lunge 
headlong,  or  which,  spreading  from  breast  to  breast,  fills  a  mob  with  reckless 
rage  or  scatters  it  in  causeless  panic.  Who  shall  say  when  the  man  could  by 
violent  effort  control  the  impulse,  and  when  llu>  impulse  of  necessity  over- 
j)owers  the  man  ?     Thus  it  is  in  all  forms  of  insanity. 

For  his  own  purposes  of  science,  or  even  of  treatment,  the  physician  needs 
no  definition  of  insanity,  but  the  relations  of  man  to  man  are  so  altered  by 
insanity  that  the  law  must  take  particular  notice  of  the  subject  of  insanity. 
Kven,  however,  for  the  purposes  of  tlu;  law  insanity  is  not  a  fixed  term, 
because  it  is  a  well-assured  axiom  that  a  man  may  be  legally  sane — /.  c. 
responsible — fi)r  one  class  of  acts,  and  insane — /'.  c.  ii'r('S])ousib!c — {\)V  another 
class  of  a(!ts. 

As  already  (contended,  there  can  l)e  no  -eieiitiru'  (leliuition  of  insanity 
except  that  it  is  a  state  of  mental  aberration.     Such  a  definition  does  not  meet 


544  MENTAL    DISEASES. 

the  needs  of  the  court-room,  which  demands  an  arbitrary  although  shifting- 
line  between  the  sane  and  the  insane.  The  term  insanity  as  used  by  judges 
and  lawyers  is  legal  rather  than  scientific,  and  the  law  ought  clearly  to  define 
the  word.  It  does,  however,  no  such  thing.  It  does  not  frame  an  authori- 
tative definition  of  insanity,  but  through  the  mouths  of  its  exponents  puts; 
forth  an  abundance  of  contradiction. 

Probably  as  good  a  definition  of  insanity  as  the  expert  can  frame  to  meet 
the  clamor  of  lawyers  is,  that  insanity  is  a  condition  of  mental  aberration  suf- 
ficiently intense  to  overthrow  the  normal  relations  of  the  individual  to  his  own, 
thoughts  and  acts,  so  that  he  is  no  longer  able  to  control  them  through  the- 
will.  The  difficulty  of  applying  this  definition  to  the  individual  case  consists^ 
in  tiie  fact  that  the  will  does  not  all  at  once  lose  its  grasp  on  the  lower  facuU 
ties,  but  that  little  by  little  these  slip  from  under  its  control.  Of  degrees  of 
responsibility  none  but  the  All-knowing  can  judge,  and  to  say  with  assured 
correctness  just  when  the  lost  control  has  been  lost  is  not  given  to  mortals. 
In  a  court  of  justice  it  becomes  the  expert  to  state  as  nearly  as  may  be  the 
exact  mental  condition  of  the  prisoner,  leaving  to  the  judge  the  decision  as  to 
his  leo-al  responsibility — i.  e.  the  relation  of  his  mental  condition  to  the  law 
of  the  commonwealth  in  which  the  trial  is  held. 

Insanity  being  a  symptomatic  condition,  and  not  a  disease,  it  is  illogical  to 
consider  its  different  forms  as  distinct  diseases.  The  best  that  can  be  done  is  to 
describe  the  diseases  of  the  brain  and  the  insanities  which  accompany  them  so 
far  as  we  know  such  diseases,  and,  when  our  knowledge  of  diseases  fails,  to 
discuss  forms  of  insanity  not  as  diseases,  but  as  symptom-groups. 

The  purposes  of  discussion  necessitate  the  naming  of  these  symptom-groups. 
Naming  symptom-groups  naturally  leads  to  the  delusion  that  these  groups  are 
diseases  ;  hence  melancholia,  mania,  etc.  are  constantly  written  about  as  though 
they  were  terms  of  equivalent  force  to  typhoid  fever  or  scarlatina,  whereas  they 
are  simply  the  names  of  symptom-groups  of  the  same  rank  as  diarrhoea,  paral- 
ysis, or  dropsy. 

This  is  shown  by  the  following  facts  : 

1st.  Similar  mental  symptoms  may  be  produced  by  various  organic  brain 
diseases;  or,  as  Dr.  Charles  F.  Folsom  says,'  "tumors,  new  growths  of  all 
kinds,  exostoses,  spicules  or  portions  of  depressed  bone,  embolisms,  hasmor- 
rhages,  wounds,  injuries,  cysticerci,  may  give  rise  to  any  of  the  symptoms  of 
the  various  psycho-neuroses  and  cerebro-psychoses." 

2d.  Almost  any  form  of  insanity  may  exist  without  demonstrable  organic 
lesion.  This  is  shown  by  the  well-known  fact  that  in  a  large  number  of 
autopsies  upon  the  insane  skilled  observers  have  failed  to  detect  alteration  of 
brain-structure. 

3d.  Antagonistic  forms  of  insanity  may  be  produced  by  lesions  which  are, 
so  far  as  we  can  perceive,  identical,  as  is  witnessed  by  the  circumstance  that 
in  paretic  dementia  the  usual  expansive  delusicms  may  be  replaced  by  a  pro- 
found  melancholy.     Further,   lesions   usually  accompanied   by  insanity  may^ 
^  American  System  of  Practical  Medicine,  vol.  v.  p.  202. 


GENERAL    COS.SIDERATIONS.  545 

exist  without  mental  disorder.  Dr.  Folsom  says :  "  Indeed,  nearly  every 
pathological  condition  of  the  brain  known  in  insanity — in  kind,  if  not  in 
extent  and  degree — may  be  found  in  diseased  or  injured  brains  where  there 
has  been  no  mental  disease  in  consequence." 

4th.  The  form  of  the  insanity  may  change  in  the  individual  without  appre- 
ciable cause  and  without  conceivable  change  of  disease. 

5th.  Almost  every  grade  of  case  exists  in  nature,  uniting  by  an  unbroken 
series  the  various  insane-symptom  groups.  Thus  of  the  two  most  antagonistic 
forms  of  acute  insanity,  acute  mania  and  acute  melancholia,  Bucknill  and  Tuke 
say  :^  "  Between  acute  mania  and  acute  melancholia  no  distinct  line  of  demarca- 
tion can  be  drawn.  The  domains  of  the  two  diseases  overlap  so  much  that,  in 
practice,  cases  not  infrequently  present  themselves  which  may  with  equal  pro- 
priety be  referred  to  one  or  the  other." 

The  considerations  which  have  been  brought  forward  show  that  the  various 
forms  of  insanity  are  not  entitled  to  be  considered  as  distinct  diseases,  and  that 
at  present  we  cannot  connect  cerebral  lesions  and  mental  symptoms  in  their 
causal  relations.  More  than  this,  the  rapid  recoveries  which  sometimes  occur 
in  apparently  hopeless  cases  of  insanity  show  that  the  symptoms  cannot  depend 
upon  alterations  of  the  brain-substance  sufficiently  gross  to  be  detected  by  our 
present  methods. 

I  shall  narrate,  as  showing  this,  a  single  case,  that  of  a  lady  with  whom  I 
was  thrown  in  almost  daily  contact  for  many  years  :  At  about  the  age  of  forty- 
five  she  was  taken  with  religious  melancholia  of  the  most  pronounced  character, 
which  was  accompanied  by  agitation,  and  sometimes  by  frenzy.  This  persisted 
for  fifteen  years.  There  had  been  in  all  this  time  not  the  slightest  wavering  of 
the  mind  of  the  woman  in  regard  to  her  future  life.  She  firmly  believed  that 
lier  soul  was  irretrievably  lost.  At  the  same  tim&  her  general  emotional  nature 
had  undergone  a  retrograde  change  :  she  had  become  exceedingly  jealous  of 
attentions  paid  to  other  persons,  and  had  lost  many  of  the  peculiar  traits  of 
refinement  which  had  been  her  especial  characteristics.  After  being  in  an  asy- 
lum for  some  time  she  recovered  intellectual  power  sufficient  to  enable  her  to 
take  charge  nominally  of  her  husband's  house,  which  was  really  managed  by 
her  attendant,  but  there  was  no  M-avering  in  her  delusion  nor  even  any  tem- 
porary abatement  of  her  misery. 

One  nio-ht  the  attendant  noticed  this  ladv  on  her  knees  at  tlie  bedside.  This 
was  the  first  time  in  fifteen  years  that  she  had  been  known  to  kneel  in  prayer. 
The  nurse,  being  a  wise  woman,  did  not  disturb  her,  and  there  she  remained 
all  night.  In  the  morning  she  joined  the  family,  and  said  that  she  had  found 
Christ,  and  that  she  was  perfectly  well  and  ha})py.  Her  old  disposition  had 
returned,  and  her  peculiar  jealous  sensitiveness  had  disapi)eared.  The  wumaii 
who  had  been  buried  for  fifteen  years  had  emerged  in  one  night  witiiout  even 
the  grave-clothes  about  her.  This  continued  loi-  one  week.  Then  the  old 
cloud  came  on  her,  and  for  days  she  was  in  the  old  condition  ;  but  suddenly 
the  sunlitrlit  ajrain  broke  throuii;h  the  clouds,  and  she  remained  well  for  three 

'  IMiila,  (.-(lition,  1874,  p.  427. 
Vol..  I.— 35 


646  MENTAL    DISEASES. 

or  four  days,  to  relapse,  and  after  some  hours  again  to  regain  her  sanity.  These 
attacks  continued  to  recur  at  gradually  lengthening  intervals.  Finally  she  had 
been  perfectly  sane  for  several  consecutive  months,  when  suddenly  she  was 
seized  with  a  serous  diarrhoea,  causeless  as  far  as  could  be  ascertained,  and 
liopeless  as  far  as  relief  by  remedies  was  concerned.  In  forty-eight  hours  she 
was  dead.  I  believe  that  the  cause  of  that  death  was  the  same  obscure  some- 
thing which  had  so  potently  aifected  for  years  the  emotional  life :  that  which 
for  so  many  years  had  dominated  the  nerve-centres  of  higher  life  attacked  and 
paralyzed  the  lower  centres  of  animal  life,  and  death  came  speedily. 

"We  can  scarcely  conceive  the  nature  of  a  lesion  which,  after  having  for  fif- 
teen years  held  the  nerve-centres  in  an  iron  grip,  suddenly  let  go  its  hold.  For 
its  demonstration  the  microscope  is  useless.  Our  best  instruments  show  us  in 
human  spermatozoa  nothing  but  irregular,  transparent  specks  of  protoplasm, 
not  to  be  distinguished  one  from  the  other.  Yet  the  records  of  past  generations 
are  written  in  the  little  formless  particles,  in  which  also  are  enfolded  the  poten- 
tialities of  future  successions  of  men.  Structure  and  function  seem  so  widely 
independent  that  it  is  almost  hopeless  to  expect  that  we  shall  ever  understand 
the  infinitely  delicate  changes  which  take  place  in  the  complex  protoplasm  of 
the  brain,  and  to  be  able  to  say  why  waves  of  emotional  and  mental  paralysis 
sweep  over  the  individual.  I  believe  that  the  changes  are  physical,  but  I 
believe  that  it  is  not  within  human  power  to  recognize  their  nature.  The 
microscope  is  a  coarse,  blundering  tool,  powerless  to  reveal  the  ultimate 
changes  of  nervous  protoplasm  gone  mad. 

I  have  ventured  to  occupy  space  with  the  above  considerations,  partly 
because  they  seem  to  me  very  important,  and  partly  because,  for  the  purposes 
of  brevity,  I  shall  omit  the  section  of  Pathology  in  the  articles  upon  the  pure 
insanities. 

A  scientific,  thoroughly  satisfactory  classification  of  insanities  is  in  the 
present  state  of  our  knowledge  probably  not  possible.  Holding  as  I  do  the 
belief  that  many  of  the  so-called  insanities  are  mere  symptom-groups  arbi- 
trarily separated,  the  simplest  arrangement  seems  to  me  the  best.  In  accord- 
ance with  this  I  shall  adopt  the  following  classification,  which  is  quite  similar 
to  that  of  Krafft-Ebing  : 

Group  I. — Complicating  Insanities. — The  outcome  of  a  distinct  organic 
disease  of  the  brain,  not  dependent  upon  acquired  or  inherited  constitutional 
diathesis. 

Meningitis,  tumors,  and  most  other  organic  brain  diseases  may  be  asso- 
(^'iated  with  disturbance  of  cerebration,  but  usually  the  mental  symptoms  are 
subordinate  to  other  evidences  of  organic  brain  disease,  and  most  of  these  dis- 
eases have  been  discussed  in  the  present  volume  under  the  head  of  Organic 
Diseases  of  the  Brain.  In  both  the  acute  and  chronic  forms  of  perien- 
(•e]>lialitis,  however,  the  evidences  of  mental  aberration  so  predominate  over 
the  physical  disturbance  that  the  subjects  usually  find  their  way  to  insane  asy- 
lums, and  the  disease  is  usually  treated  of  in  text-books  on  insanity,  and  this 
custom  is  here  followed. 


GENERAL    CONSIDERATIONS.  647 

The  mental  aberration  and  deterioration  of  old  age  are  commonly  supposed 
to  be  dependent  upon  organic  change.  In  accordance  with  this  view  I  shall 
consider  it  in  the  present  group.  Amentia,  or  imbecility  from  arrest  of  devel- 
opment, may  also  well  be  considered  as  among  the  organic  insanities. 

Ch'oup  II. — CoxsTiTUTioxAL  INSANITIES,  in  which  the  cerebral  disorder 
is  due  to  an  acquired  or  inherited  constitutional  disease,  including  in  the  latter 
term  diathesis,  constitutional  diseases,  and  subacute  and  chronic  poisonings 
involving  widespread  areas  of  the  body. 

The  most  important  of  the  diathetic  insanities  are  the  gouty,  the  epileptic, 
the  hysterical,  and  the  syphilitic.  Numerous  poisons  disturb  cerebration,  but 
the  only  toxaemic  insanity  which  it  seems  necessary  to  notice  at  this  place  is 
that  due  to  alcohol. 

Group  III. — Pure  Insanities,  in  which  the  mental  disorder  is  not 
dependent  either  u{)on  demonstrable  organic  brain  lesion  or  upon  a  diathetic 
or  other  poison.  The  pure  insanities  seem  to  me  very  naturally  divided  into 
two  subgroups,  which  may  be  known  as  the  Functional  Insanities  and  the 
Neuropathic  or  Constitutional  Insanities. 

The  Functional  Insanities  are  those  insanities  which  are  liable  to  occur  in 
almost  any  person,  or  at  least  which  do  occur  in  individuals  who  have  pre- 
viously shown  no  mental  warp,  and  who  may  recover  and  during  later  life 
remain  free  from  mental  aberration.  Conditutional  Insanities  are  the  out- 
irrowth  of  an  orio^inal  vice  of  nervous  construction,  such  vice  of  construction 
not  being  sufficient  to  reveal  itself  by  anatomical  peculiarities,  but  showing 
its  presence  throughout  life  in  functional  aberration.  The  general  tendency 
of  constitutional  insanity  is  to  increase  in  severity  as  the  patient  grows  older, 
and  a  constitutional  insanity,  once  developed,  is  rarely  if  ever  permanently 
recovered  from.  It  is  especially  these  forms  of  insanity  which  grade  so  insen- 
sibly into  sanity.  At  the  bottom  of  the  series  is  the  typical  human  individ- 
ual ;  then  the  man  who  is  original  and  strikingly  independent  in  thought  and 
act ;  then  tiie  man  who  is  so  set  apart  by  mental  peculiarities  from  his  fellows 
that  he  is  known  as  eccentric ;  then  the  lunatic,  eccentricity  grading  by  an 
unbroken  series  into  a  complete  insanity,  the  subject  of  which  is  not  to  be 
influenced  by  the  motives  which  usually  dominate  men,  and  is  indeed  incapa- 
ble of  reasoning  correctly  or  indeed  of  controlling  his  own  acts. 

Functional  Insanities.  Neuropathic  Insanities. 

Melancholia.  Constitutional   affective   insanity  (folic 

raisonante). 
Mania.  Moral  insanity. 

Confusional  insanity.  Paranoia  — insanity     wilh     irresistible 

ideas. 
Terminal  dementia.  T^eriodic  insanity  (folic  circulaire). 


548  3IEXTAL    DISEASES. 

GROUP   I.— ORGANIC   INSANITIES. 

Acute  Periencephalitis. 

Definition. — A  very  acute,  usually  fatal,  disease  of  the  brain,  attended  by 
stupor,  wild  delirium,  general  disturbance  of  the  psychic  functions,  by  rest- 
lessness, convulsions,  and  other  disturbances  of  the  motor  function,  and  by 
fever;  dependent  upon  acute  hypersemia  and  subsequent  inflammatory  changes 
in  the  brain  cortex. 

Synoxyms.— Acute  peripheral  encephalitis ;  Phrenitis  mania  gravis ;  Typho- 
mania  ;  Acute  delirium  ;  Delirium  grave  ;  Bell's  disease  (Luther  Bell). 

Pathology. — P^xcessive  hypersemia  aifecting  both  the  cerebral  cortex  and 
its  membranes  is  the  first  alteration  in  the  present  affection.  This  is  rapidly 
followed  by  oedematous  exudation,  with  a  choking  up  of  the  lymph-spaces 
both  of  the  pia  and  the  cortex  by  the  corpuscular  elements  of  the  blood.  The 
periglanglion  space,  as  well  as  the  interstitial  lymph-sheaths,  becomes  crammed 
with  these  bodies.  I  have  myself  seen  also  minute  apoi)lectic  haemorrhages  in 
the  gray  matter.  In  one  case  which  I  examined  the  ganglionic  cells  themselves 
appeared  to  have  undergone  some  change. 

Etiology. — Acute  periencephalitis  appears  to  occur  fully  as  frequently  in 
women  as  in  men,  and  usually  during  active  adult  life.  Abuse  of  alcohol, 
profound  grief,  protracted  worry,  especially  when  accompanied  by  great  over- 
work, partial  starvation  combined  with  the  gnawing  anxiety  of  deep  poverty, 
certain  acute  fevers,  sunstroke,  blows  upon  the  head, — these  are  commonly 
assigned  as  the  causes  of  the  disorder,  which  also  in  some  cases  appears  to 
have  been  the  result  of  chronic  disease  of  the  skull  or  its  membranes.  The 
affection  may  also  develop  as  an  exacerbation  of  chronic  periencephalitis,  and 
I  have  seen  it  come  on  without  apparent  cause  during  locomotor  ataxia. 
Recorded  cases  of  death  from  alleged  acute  hysteria  have  probably  been 
instances  of  this  disease.  The  combination  of  overwhelming  mental  and 
phvsical  strain  is  ]>erhaps  the  reason  of  the  comparative  frequency  of  the  dis- 
order during  ])rcgnancy  following  seduction. 

The  symptoms  may  come  on  with  extreme  suddenness  or  may  be  preceded 
l)v  prodromic  evidences  of  cerebral  disturbance.  These  prodromes  in  rare 
cases  take  the  form  of  increase  of  mental  power,  in  others  of  brief  nocturnal 
attacks  of  wandering,  delirious  restlessness ;  or  there  may  be  short  periods  of 
impaired  consciousness,  especially  upon  waking  in  the  morning,  or,  as  in  one 
of  my  cases,  even  an  epileptiform  convulsion.  The  fully- developed  disorder 
naturally  divides  itself  into  two  stages — first,  that  of  acute  maniacal  delirium  ; 
and  second,  that  of  apathy  and  collapse,  with  coma. 

The  delirium  is  always  of  an  excited  type,  accomjianied  by  violent  inco- 
herent speech,  and  usually  by  a  fury  of  fighting  and  of  destructiveness.  Hal- 
lucinations and  half-formed  delusions  are  present,  and  often  bear  a  close 
relation  to  tlie  cause  of  the  attack.  The  abandoned  mistress  will  in  her 
ravings  recount  her  past  shame  and  present  agony.  The  business-man  will 
be  perpetually  occupied  with  an  incoherent  jumble  of  business  transactions. 


ACUTE   PERIEXCEPHALiriS.  549 

Almost  invariably  along  with  the  delirium  there  is  great  physical  restlessness, 
which  grows  more  intense  until  it  causes  the  patient  to  leap  from  his  bed  and 
to  attempt  to  run  away.  Very  commonly  violent  assaults  are  made  upon  the 
attendants.  Convulsions  are  rare.  The  delirium  may  at  first  be  not  continuous, 
occurring  only  at  night,  or  at  least  be  interrupted  by  brief  intervals  of  compar- 
ative rationality  during  the  daytime.  Finally,  however,  there  is  persistent 
intense  mania.  In  one  of  my  cases  the  patient  during  the  day  told  his  wife 
that  she  must  protect  herself  from  him — that  he  loved  her  most  fondly,  bnt  that 
he  was  o-oins;  into  a  condition  of  insanity  in  which  he  would  certainlv  kill  her. 
From  this  time  until  his  death  he  was  furiously  maniacal  during  the  night, 
although  for  several  days  he  would  recognize  his  friends  during  the  daytime, 
and  for  a  moment  or  two  talk  rationally.  There  is  usually  absolute  insomnia. 
The  pulse  is  rapid,  and,  if  in  the  beginning  it  possesses  a  show  of  force,  it  is  really 
soft  and  compressible.  There  is  no  desire  for  food,  and  generally  an  absolute 
refusal  to  take  it.  There  is  also  distinct  fever,  the  temperature  rising  some- 
times to  106°  F.  According  to  my  observation,  the  temperature  varies  with 
a  stormy  irregularity  which  is  almost  characteristic,  rising  and  falling  many 
deorrees  many  times  during;  the  twenty-four  hours.  Its  variations  are  connected 
with  the  mental  and  physical  excitement  of  the  patient,  maniacal  outbursts 
producing  an  immediate  rise  of  the  temperature.  In  advanced  stages  the 
temperature  may  fall  much  below  the  normal.  The  pupils  may  be  contracted, 
dilated,  or  normal.  In  the  course  of  a  few  hours  to  several  days  the  second 
stage  of  the  disorder  develops.  There  is  now  quiet,  with  coma  or  else  mutter- 
ing, delirious  unconsciousness,  failing  pulse,  cool  skin,  and  general  evidences 
of  collapse.  In  the  early  part  of  this  stage,  when  aroused,  the  patient  may 
respond  incoherently  or  perhaps  give  some  slight  evidences  of  comprehending 
what  is  said  to  him,  but  rapidly  sinks  lower  and  lower  until  he  dies  from 
exhaustion.  Early  in  the  disorder  the  skin  becomes  very  harsh,  and  finally 
cyanotic ;  in  the  later  stages  irregular  desquamation,  or  even  ulceration,  may 
occur.  In  a  case  quoted  by  Spitzka  the  ansesthesia  was  so  complete  that  the 
patient  gnawed  off  a  portion  of  one  of  his  fingers.  Pemphigus-like  vesicles, 
phlegmons,  decubitus,  gangrenous  patches  of  skin,  or  gangrenous  extremities 
not  rarely  apjiear,  but  are  frequently  absent,  and  are  not  characteristic. 

Diagnosis. — Diseases  having  no  connection  with  the  brain  may  sometimes 
sinudate  an  acute  periencephalitis.  This  is  especially  true  of  the  abrujit  mania- 
cal outbreaks  which  sometimes  occur  in  a  latent  overlooked  pneumonia.  Tlie 
fact  that  acute  delirium  is  a  disease  of  jniddle  life,  whilst  the  so-called  cerebral 
pneumonia  occurs  almost  exclusively  in  young  children  or  in  persons  broken 
down  by  age,  excesses,  or  privations,  should  put  the  practitioner  on  his  guard, 
and  a  physical  examination  woidd  detect  a  pidmonic  disease.  Typhomania  is 
distinguished  in.iii  acnite  meningitis  by  the  absence  of  general  hyperesthesia, 
^iffness  of  the  muscles  of  the  back  or  extremities,  and  of  |)ronounced  head- 
ache. In  acute  mania  the  bodily  temperatun;  is  usually  normal  or  subnormal, 
and,  according  to  Krafft-Ebing,  the  rise  of  tiie  temperature  in  such  a  case  to 
100.5°  F.  indi<-at('S  strongly  delirium  aciituin. 


550  MENTAL    DISEASES. 

Prognosis. — The  prognosis  is  highly  unfavorable:  about  two-thirds  of  the 
cases  end  fatally,  and  when  recovery  occurs  the  mind  is  almost  universally  left 
more  or  less  affected.  Alcoholic  cases  are  especially  dangerous  :  the  more  vio- 
lent the  delirium,  the  insomnia,  the  motor  disturbance,  or  the  fever,  the  worse 
the  outlook. 

Treatment. — In  the  early  stages  of  delirium  acutum  general  or  local  blood- 
letting by  means  of  leeches,  irritating  purgatives,  the  local  application  of  cold 
to  the  head,  seem  to  be  strongly  indicated,  whilst  hypodermic  injections  of 
morphine  and  of  hyoscine,  with  the  administration  of  chloral  by  the  mouth, 
serve  to  allay  the  excitement.  Much  better  results  are  obtained  by  repeating 
the  remedies  at  short  intervals  in  comparatively  small  doses  than  by  giving 
large  doses  at  long  intervals.  The  Italian  physician  Solivetti  has  claimed  ex- 
traordinary results  from  hypodermic  injections,  every  eight  hours,  of  1  gramme 
of  ergotin.  Certainly  the  use  of  ergot  would  seem  to  be  indicated,  and  the  se- 
verity of  the  disorder  thoroughly  justifies  the  risk  of  any  local  trouble  from 
hy])odermics.  A  filtered  solution  of  the  officinal  extract  of  ergot  in  freshly- 
boiled  water  should  be  used.  In  the  later  stages  of  the  disorder  alcoholic  and 
cardiac  stimulants  may  be  employed  p7'0  re  nata.  Throughout  the  disease 
everv  effort  should  be  made  to  obtain  absolute  rest,  with  freedom  from  the 
causes  of  excitement,  whilst  milk,  eggs,  and  similar  nourishing,  non-irritating 
foods  should  be  administered  as  freely  as  the  patient  will  take  them. 

Chronic  Periencephalitis. 

Definition. — A  chronic  disease,  dependent  upon  a  peculiar  inflammatory 
degeneration  of  the  cerebral  cortex,  which  gives  rise  to  change  of  character ; 
progressive  mental  deterioration,  with  delusions  of  grandeur,  emotional  exalt- 
ation or  emotional  depression  ;  occasional  maniacal  outbreaks  and  epileptic 
attacks;  progressive  physical  deterioration,  as  shown  by  irregularity  of  the 
pupils,  disorder  of  speech,  loss  of  control  over  the  movements  of  the  hands 
and  legs, — all  symptoms  finally  being  swallowed  up  in  a  complete  paralysis 
of  intellection  and  of  voluntary  motion. 

Synonyms. — Paretic  dementia  ;  General  paralysis  of  the  insane  ;  Paresis ; 
Dementia  paralytica ;  Periencephalo-meningitis. 

Btiolog-y. — Heredity  plays  a  very  unimportant  role  in  the  production  of 
general  paralysis,  a  positive  taint  being  present  only  in  about  15  per  cent,  of 
the  cases.  The  disease  is  very  uncommon  in  females,  and  exceedingly  rare  in 
females  of  the  upper  classes,  whilst  it  is  remarkably  frequent  in  officers  and 
other  military  officials,  in  whom,  according  to  Mickle,  it  also  occurs  at  an 
earlier  age  than  in  other  persons.  Thus  in  civil  life  the  affi-ction  is  most  fre- 
quent between  forty  and  fifty,  and  extremely  rare  under  thirty  or  over  sixty, 
whilst  in  sailors  and  soldiers  it  is  affirmed  by  Mickle  that  the  average  age  is 
about  thirty-three.  These  jieculiarities  are,  however,  probably  simply  depend- 
ent upon  diffiirences  of  exposure  to  tlie  three  great  causes  of  the  disorder — 
namely,  alcoholic  and  venereal  excesses,  sy])hilis,  and  habitual  long-continued 
over-exertion,  accom])anied    by  the  strain  of  excessive  ambition  or  of  worry. 


CHRONIC  PERIENCEPHALITIS.  551 

The  connection  between  the  disease  and  sypliilis  is  distinct.  Mendel  affirms 
that  in  general  paralysis  75  per  cent,  of"  the  victims  offer  a  distinct  history  of 
syphilis,  whilst  only  18  per  cent,  of  the  victims  of  other  insanities  investigated 
by  him  were  syphilitic.  The  relations  between  the  two  diseases  are  evidently 
precisely  those  which  exist  between  syphilis  and  locomotor  ataxia  :  dementia 
paralytica,  indeed,  occurs  not  rarely  as  a  complication  of  tabes  dorsalis,  whilst 
spinal  scleroses  are  not  rare  in  dementia  paralytica.  Sunstroke  and  blows 
upon  the  head  are  also  set  down  by  authorities  as  among  the  exciting  causes 
of  periencephalitis. 

Pathology. — At  autopsies  upon  old  cases  of  chronic  periencephalitis  are 
usually  found  hyperostosis  and  exostosis  of  the  skull ;  pachymeningitis  in 
some  form  (often  absent) ;  arachnitis  (with  consolidation  of  the  arachnoid  with 
the  brain);  atro])hy  of  the  convolutions,  especially  of  the  frontal  lobes;  and 
internal  hy drocephal us. 

Two  distinct  views  ])revail  as  to  the  nature  of  the  disease-process  :  one, 
that  it  is  a  diffused  interstitial  cortical  encephalitis,  in  which  the  connective 
tissue  is  primarily  affected  ;  the  second,  that  it  is  a  diffused  parenchymatous 
inflammation,  which  commences  in  the  nerve-elements  proper  and  involves 
secondarily  the  neurogliar  tissue. 

On  section  the  brain-cortex  is  usually  found  discolored,  sometimes  less, 
sometimes  more  firm,  than  normal,  often  containing  minute  cysts  or  cavities 
varying  in  size  from  a  pin's  point  to  a  millet-seed.  Microscopic  examination 
reveals  degeneration  or  perhaps  complete  disappearance  of  the  ganglionic  cells 
and  a  peculiar  alteration  of  the  white  fibres,  which  renders  them  much  more 
apparent  than  in  the  healthy  brain,  besides  pronounced  degeneration  of  the 
neuroglia  and  large  numbers  of  peculiar  many-processed  connective-tissue  cells 
(Deiter's  or  spider-shaped  cells).  The  blood-vessels  are  usually  injected, 
altered  in  character,  with  distension  of  the  adventitial  lymph-spaces.  The 
spinal  cord  is  very  frequently  degenerated.  Changes  in  the  sympathetic 
ganglia  have  also  been  noted  by  recent  investigators. 

Symptomatolog-y. — The  symjitoms  of  general  paralysis  vary  so  greatly 
that  it  is  exceedingly  difficult  to  reduce  theui  to  order.  Four  stages  of  the 
disease  are  recognized  by  some  writers,  but  the  individual  case  usually  passes 
bv  such  im])erceptiblc  degrees  from  bad  to  worse  that  these  divisions  nnist  be 
looked  upon  as  arbitrary.  Moreover,  in  various  cases  the  time  relations  of 
these  stages  vary,  and  some  of  the  stages  are  often  altogether  absent  or  jiass 
unobserved.  Nevertheless,  for  the  purposes  of  discussion  I  shall  speak  briefly 
of  these  four  stages,  and  then  take  up  the  consideration  of  the  individual 
symptoms  of  the  disorder. 

The  first  or  prodromic  stage  often  passes  without  recognition.  The  syni])- 
toms  may  resemble  those  of  an  ordinary  cerebral  neurasthenia — loss  of  ])owcr 
of  fixing  the  attention,  apathy,  inability  for  mental  exertion,  and  some  em(»- 
tional  departure  from  health.  Tn  some  cases  vaso-motor  phenomena  arc  pro- 
noun('cd,  showing  themselves  in  {\\i-'\\\\  congestion,  headache,  vertigo,  tinnitus 
aurinin,  liciiii;iiiopsia,  and   even   pcciiliar  disliirbnnccs  of  vision,  siiiiuliiting  au 


552  MENTAL    DISEASES. 

acute  glaucoma.  At  the  same  time  a  slight  alteration  of  character  is  evident 
to  the  close  observer,  the  patient  being  in  some  way  not  himself.  Krafft- 
Ebino-  gives  as  almost  characteristic  the  peculiar  alteration  of  the  relations 
of  the  patient  to  time  and  space,  which  render  him  exceedingly  unpunctual 
or  cause  him  at  times  confusedly  to  lose  himself  in  well-known  streets.  Al- 
thouirh  this  stage  is  so  often  overlooked,  yet  after  the  disease  has  declared 
itself  the  books  and  correspondence  of  the  business-man  or  the  office  histories 
and  records  of  the  professional  laborer  will,  in  their  loss  of  accuracy  and  dignity 
and  in  their  general  evidences  of  failing  power,  afford  a  history  of  a  slowly- 
progressive  mental  degeneration. 

The  second  stage  of  the  disease  is  that  in  which  the  mental  aberration  is 
pronounced  and  distinct.  The  disordered  cerebration  may  be  accompanied  by 
distinct  disturbance  of  the  motor  faculties,  but  I  have  seen  it  persist  for  more 
than  a  year  without  the  slightest  failure  of  the  general  physical  powers. 

The  third  stage  of  the  disease  is  that  in  which  motor  symptoms  become 
marked,  as  shown  in  inequality  of  the  pupils,  flabbiness  and  loss  of  expression 
of  the  face,  disorders  of  articulation,  general  loss  of  endurance,  and  mayhap 
distinct  paresis  of  the  extremities. 

The  fourth  stage  of  the  disease  is  that  in  which  the  dementia  is  complete, 
and  the  general  widespread  paralysis  and  loss  of  power  profound,  the  patient 
being  reduced  to  a  mere  living  automaton. 

For  the  purposes  of  discussing  the  mental  phenomena  of  paretic  dementia 
the  cases  may  be  divided  into  four  groups,  it  being  remembered  that  in  nature 
every  grade  of  case  exists  between  these  groups,  whilst  the  march  of  the  men- 
tal malady  is  sometimes  so  irregular  that  in  one  portion  of  its  career  the  case 
would  be  properly  assigned  to  one  group,  whilst  at  another  period  it  would 
represent  another  variety  of  the  disorder. 

In  the  first  form  of  j^aretic  dementia  are  included  those  cases  in  which 
])rogressive  failure  of  power  constitutes  almost  the  whole  mental  disturbance, 
the  mental  faculties  consentaneously  growing  less  and  less  until  the  patient 
becomes  childish,  and  at  last  completely  demented,  without  emotional  disturb- 
ance or  delusions  having  been  present.  (It  is  these  cases  especially  that  are 
[»opularly  spoken  of  as  softening  of  the  hrain?) 

The  second  variety  of  paretic  dementia  is  that  in  which  delusions  of 
grandeur  or  expansive  delirium  are  present.  The  character  of  these  delusions 
lias  already  been  sufficiently  pointed  out.  (See  page  537.)  It  is  essential  to 
remember  that  these  delusions  mav  exist  in  so  mild  a  deo:ree  that  thev  mav 
be  very  readily  overlooked.  Further,  in  many  cases  they  are  replaced  by  a 
Inen-^tre  which  may  be  looked  upon  as  a  condition  of  undeveloped  delusion. 
Thus  the  man  sunk  in  the  deepest  poverty  will  be  excessively  happy  and 
Jolly,  misfortunes  having  no  power  to  depress  him,  although  he  makes  no 
assertion  of  the  ]iossession  of  great  power  or  wealth.  In  all  cases  of  the  present 
variety  of  general  paralysis  there  is  progressive  mental  failure,  and  it  is  there- 
fore evident  that  the  cases  in  which  a  simple  hien-Mrc  exists  may  be  looked 
upon  as  midway  between  the  first  and  the  second  variety  of  the  disease. 


CHRONIC  PERIEXCEPHALITI^.  553 

Maniacal  outbursts  may  occur  in  any  variety  of  general  paralysis,  but  they 
are  more  common  and  more  frequent  when  there  are  delusions  of  grandeur. 

The  third  form  of  general  paralysis  is  that  in  which  there  is  emotional 
depression,  and  even  pronounced  melancholia,  with  depressive  delusions.  Not 
rarely  the  depressive  delusion  relates  to  the  person  of  the  ]>atient,  who  believes 
himself  ill,  deformed,  or  wanting  in  some  member  or  function.  In  this  way 
arises  the  so-called  hypochondriacal  variety  of  general  ])aralvsis. 

The  fourth  form  of  general  paralysis  is  that  described  by  Dr.  Fabre,  in 
which  excitement  and  depression  alternate  so  as  to  make  a  periodic  or  circular 
insanity.  The  existence  of  this  variety  has  been  confirmed  by  Dr.  W.  Julius 
Mickle,^  who  further  says  that  when  there  are  only  two  phases  these  succeed 
each  other  suddenly,  but  that  in  some  cases  there  are  three  periods — (1)  excite- 
ment, (2)  calm,  (3)  depression,  in  this  differing,  therefore,  from  non-paralytic 
circular  insanity,  in  which  the  usual  order  is  (1)  excitement,  (2)  depression, 
(3)  quietude  or  lucidity. 

The  motor  symptoms  of  paretic  dementia  consist  of  epileptiform  convul- 
sions and  paralysis.  The  paralysis  is  characterized  by  its  incompleteness  and 
its  connection  with  tremors  and  disorders  of  co-ordination.  In  the  earliest 
stages  of  the  disorder  the  loss  of  control  over  complicated  muscular  move- 
ments is  first  manifested  in  the  hands,  and  may  be  very  ]M'onounced  at  a  time 
when  the  general  muscular  ]>ower  is  but  little  weakened.  Thus,  a  man  may 
be  able  to  lift  many  pounds,  although  he  cannot  write  his  own  name.  The 
acute  development  of  such  a  loss  of  muscular  control,  occurring  in  a  man  of 
middle  age,  without  obvious  cause,  is  a  serious  symptom,  and  probably,  in  the 
majority  of  cases,  is  prodromic  of  general  paralysis.  It  is  especially  to  be 
noticed  very  early  in  engravers  and  other  persons  whose  daily  vocation 
requires  great  technical  skill. 

A  varying  inequality  of  the  pupils  may  occur  very  early,  although  more 
constant  in  the  later  stages  of  the  disease.  It  mav  be  associated  with  exces- 
sive  dilatation  or  contraction.  When  there  is  no  affection  of  the  eye  or  its 
nerves,  no  focal  brain  lesion,  and  no  disease  of  the  nock  or  of  the  cervical 
spinal  cord,  this  symptom   is   very  characteristic. 

The  departure  of  the  speech  from  the  norm  in  general  jxiralysis  is  partially 
of  mental  and  partially  of  physical  origin.  As  a  consequence  of  the  loss  by 
the  lips  and  tongue  of  their  delicacy  of  movement  there  is  a  difficulty  of  pro- 
nunciation, which  is  especially  manifested  with  lingual  and  labial  consonants 
an<l  in  the  syllables  of  long  words.  This  causes  a  ])eculiar  stuttering  or  hesi- 
tation, with  some  thickness  of  speech  and  an  occasional  elision  of  syllables,  so 
that  the  speech  somewhat  resembles  that  of  intoxication.  In  advanced  stages 
of  the  disease  the  uncertainty  of  the  movements  of  the  lips  and  tongue  is 
plairdy  visible  to  the  eye,  and  is  associated  willi  tremor,  or,  more  correctly, 
with  tremulousncss.  In  general  paralysis  the  mind  thiidcs  slowly  and  imper- 
fectly :  it  fails  not  only  in  flic  firmation  of  ideas,  l)nt  also  in  the  quick  asso- 
ciation  of  these   ideas   with   suitable  words.      There   is,  eonscMiuently,  slowness 

'  (InuTiil  PdinlijKis,  London,  1880. 


554  MENTAL    DISEASES. 

as  well  as  hesitation  of  speecli.  In  some  cases  the  mental  actions  seem  to  be 
performed  in  a  rhythmical  manner,  giving  rise  to  a  peculiar  utterance  which 
somewhat  resembles  that  used  by  the  school-boy  in  scanning  Latin  poetry,  and 
hence  often  spoken  of  as  the  "  scanning  speech."  There  is  also  in  many  cases 
a  use  of  improper  words.  Not  rarely  the  paralytic  talker  drops  a  word  from 
his  sentence  or  repeats  a  word ;  mayhap  he  elides  or  repeats  a  whole  clause. 
Movements  of  the  jaws  similar  to  mastication  may  take  place,  and  even  cause 
grinding  of  the  teeth  or  champing  of  the  jaws. 

The  loss  of  adroitness  and  exactitude  of  movement  may  first  appear  in  the 
hands.  The  handwriting  becomes  shaky  and  irregular,  and  the  letters  are  ill 
formed,  even  widely  separated  from  one  another,  sometimes  resembling  hiero- 
glyphs rather  than  members  of  the  Roman  alphabet.  Very  frequently  the 
finely-graded  strokes  of  correct  writing  disappear  in  a  common,  thick,  uncer- 
tain line.  The  writing  not  only  shows  the  physical  degradation,  but  has  the 
same  mental  characteristics  as  the  speech.  The  ideas  are  often  incongruous 
and  devoid  of  proper  association  and  the  words  incorrectly  used.  Letters  are 
dropped  out,  syllables  omitted  or  repeated,  and  words  or  even  clauses  elided  or 
interjected. 

The  gait  may  be  early  affected.  It  becomes  awkward  and  uncertain  ;  the 
steps  may  be  long  and  slightly  irregular  ;  and  the  patient's  lack  of  control  over 
his  movements  comes  out  sharply  when  he  attempts  suddenly  to  turn  or  to 
alter  his  position.  As  the  disease  progresses  the  gait  becomes  slow,  heavy,  and 
unsteady,  whilst  the  widely-separated  feet  readily  trip  over  an  inequality  or 
unexpected  obstacle.  In  the  advanced  stages  the  posture  of  the  patient  resem- 
bles that  of  old  age,  the  body  being  bent  awkwardly  forward  or  to  one  side. 
With  difficulty  he  walks  with  a  slow,  unsafe,  swerving  gait,  in  the  most 
advanced  stages  tottering  forward,  aided  by  an  arm  or  some  support,  and  day 
l)y  day  losing  control  over  his  limbs  until  he  becomes  bedridden. 

Epileptic  convulsions  may  occur  in  the  beginning  of  a  general  palsy,  and 
may,  indeed,  usher  in  the  first  distinct  symptoms  of  the  disease.  Under  such 
circumstances  their  significance  may  readily  be  overlooked.  This  is  especially 
the  case  when  the  major  attacks  are  replaced  by  or  associated  with  petit  mal, 
in  which  the  only  symptom  of  the  seizure  may  be  a  sudden  pallor  with  mental 
confusion  or  a  momentary  unconsciousness,  or  a  dilatation  of  the  pupils  with 
drawing  of  the  head,  or  a  sudden  fixation  of  the  countenance  with  an  outpour- 
ing of  cold  perspiration,  or  an  automatic  repetition  of  coherent  or  incoherent 
l)hrases.  Such  paroxysms  are  apt  to  be  interj)reted  as  syncopal,  or  sometimes 
as  apoplectiform.  Not  rarely  epilepsy  in  general  paralysis  takes  upon  itself 
the  Jacksonian  form,  the  convulsion  being  limited  to  isolated  groups  of  mus- 
cles, or  to  one  side  of  the  face,  one  leg,  or  one  arm,  or  being  hemiplegic. 
Usually  the  attack  begins  with  an  aura,  which  is  especiallv  apt  to  be  ver- 
tiginous. Sometimes  the  convulsion  is  preceded  for  several  days  by  excessive 
restlessness,  tinnitus  aurium,  and  great  psychical  excitation.  In  other  cases 
it  begins  with  vomiting. 

The  epileptic  attacks  are  apt  to  become  more  and  more  frequent  as  the  dis- 


CHRONIC  PERIENCEPHALITIS.  555 

ease  advances,  and  the  observation  of  Esquirol  that  a  succession  of  epileptic 
fits  frequently  closes  the  scene  in  general  has  received  abundant  confirmation. 
When  the  true  epileptic  status  occurs  during  a  general  paralysis  the  successive 
convulsions  are  often  very  diverse,  one  being  complete,  the  next  partial — in 
one  the  head  being  drawn  to  the  right,  in  the  next  to  the  left,  and  so  on. 
Frequently  after  the  paroxysms  convulsive  tremblings  persist  in  single  mus- 
cles or  in  groups  of  muscles  for  many  hours,  and  are  followed  by  a  more 
or  less  pronounced  partial  palsy.  To  use  the  words  of  Dr.  Nichol,  paralysis 
follows  the  convulsion  or  spasm  as  the  shadow  follows  the  body.  During  the 
more  severe  paroxysms  consciousness  is  always  lost,  but,  especially  when  the 
convulsive  movements  are  more  or  less  local,  it  may  be  perfectly  maintained ; 
occasionally  it  is  affected  as  in  hysteria.  After  severe  seizures  the  mental  con- 
dition of  the  pijtient  is  almost  always  distinctly  aggravated. 

It  is  affirmed  by  many  authors  that  in  general  paralysis  apoplectic 
attacks  followed  by  a  temporary  hemiplegia  sometimes  seem  to  replace  the 
epilejitic  paroxysms.  Vaso-motor  disturbances  may  occur  among  the  pro- 
dromes of  dementia  paralytica,  revealing  themselves  in  loss  of  tone  in  the 
pulse ;  in  sudden  attacks  of  localized  vaso-motor  paralysis,  often  affecting  the 
face  and  head  and  accompanied  with  vertigo  ("  rush  of  blood  to  the  head  "),  or 
giving  rise  to  localized  superficial  alterations  of  temperature,  or  even  to  local- 
ized sweatings.  In  the  later  stages  the  widespread  cyanosis,  superficial  oedema, 
and  coldness  of  the  extremities,  with  the  frequent  neuro-paralytic  hypersemia 
of  the  internal  organs,  indicate  the  loss  of  power  in  the  vaso-motor  centres. 
Probablv  to  a  trophic  rather  than  to  a  vaso-motor  disturbance  belong  the  fre- 
quent attacks  of  herpes  zoster  and  other  herpetic  eruptions. 

Disturbances  of  sensibility  beyond  a  mere  passing  numbness  are  very  rare 
in  the  early  stage  of  dementia  paralytica.  Violent  lancinating  pains,  when 
present,  are  proof  of  the  development  of  tabes.  In  the  advanced  stages  general 
sensibility  is  lessened  and  may  be  almost  destroyed,  or,  Avhat  is  perhaps  more 
frequent,  tactile  sensation  may  be  preserved  to  some  extent  whilst  the  anal- 
gesia is  complete.  This  condition  often  leads  to  accidents  which  are  only  to  be 
prevented  by  the  greatest  care.  Thus,  I  have  known  a  paretic  dement  scald 
himself  to  death  by  getting  into  an  overheated  bath,  and  all  kinds  of  injuries 
are  from  time  to  time  reported  in  the  journals.  Violent  sexual  excitement  is 
often  one  of  the  earliest  symptoms  of  general  paralysis,  but  in  the  progress 
of  the  disease  it  gradually  gives  way  to  impotence,  excessive  libidinousncss 
often  persisting  after  the  total  loss  of  sexual  power. 

Disturbances  of  temperature,  especially  a  tendency  to  an  evening  rise  and 
to  irregular  paroxysmal  alterations  of  temperature  without  apparent  cause,  are 
very  frequent  in  general  paralysis.  Especially  characteristic  is  a  tendency  fi)r 
violent  fever  to  be  produced  by  every  slight  cause.  The  ej)ileptic  ])arox- 
ysms  are  often  accompanied  by  a  marked  rise  of  temjjerature,  which  caimot 
altogether  be  dependent  upon  the  convulsion,  since  it  fretpiently  precedes 
bv  as  much  as  eight  or  ten  hours  the  development  of  the  atlack,  and  often 
lasts   twentv-foiir   hours  alter  the   fit.      Moreover,   violent  epileptic  fits    may 


556  MENTAL    DISEASES. 

occur  without  elevation  of  the  temperature,  and  both  Mendel  and  Westphal 
have  put  on  record  cases  in  which  a  violent,  long-continuing  epileptic  paroxysm 
was  accompanied  and  followed  by  a  marked  fall  of  temperature.  Usually, 
however,  a  distinct  drop  in  the  temperature  at  the  close  of  an  attack  of  uncon- 
sciousness marks  the  occurrence  of  a  true  apoplexy.  Irregularity  in  the 
temperature  of  the  two  sides  of  the  body  seems  not  to  be  rare  in  advanced 
dementia,  in  which  condition  there  is  also  a  tendency  to  subnormal  temperature. 

Diag-nosis. — A  positive  diagnosis  in  the  prodromic  stages  of  general  paraly- 
sis is  not  possible,  so  that  the  greatest  care  must  be  exercised  in  making  state- 
ments to  the  friends  of  the  patient,  although  sufficient  certainty  may  exist  for 
the  purposes  of  treatment.  Marked  alterations  of  character  occurring  at  this 
time  are  very  significant.  (  See  page  552.)  In  the  more  advanced  stages  of  the 
disorder  it  is  essential  to  separate  syphilitic  and  focal  organic  disease.  For 
diagnosis  between  dementia  paralytica  and  cortical  syphilis  see  page  730.  Focal 
disorders  are  at  once  distinguished  by  the  fact  that  in  them  the  tendency  is  to 
localized  paralysis,  whereas  in  general  paralysis  the  tendency  is  primarily  to 
loss  of  co-ordination,  and  latterly  to  a  widespread  muscular  weakness  rather 
than  a  distinct  localized  paralysis. 

In  those  cases  in  which  the  mental  disorder  precedes  for  a  great  length  of 
time  the  development  of  physical  symptoms  the  diagnosis  must  be  between 
dementia  paralytica  and  a  pure  insanity.  Irregularity  of  the  pupil  under  such 
circumstances  would  be  an  almost  deciding  symptom,  and  usually  mere  loss 
of  power  in  the  execution  of  fine  movements,  such  as  those  of  writing,  but- 
toning and  unbuttoning  the  clothing,  dancing,  etc.,  can  be  detected  in  the 
paretic  dement  even  when  the  general  muscular  power  is  very  good.  If  this 
cannot  be  done,  a  study  of  the  memory  becomes  important.  Distinct  and  pro- 
gressive failure  of  memory  in  a  patient  whose  mental  symptoms  correspond  to 
those  of  a  commencing  general  paralysis  is  almost  positive  proof  that  the  case 
does  not  belong  among  the  pure  insanities. 

Prognosis. — The  prognosis  of  acute  })eriencephalitis  is  very  unfavorable 
if  the  diagnosis  be  positively  made  out:  the  most  that  can  be  hoped  for  is  to 
obtain  a  remission  of  the  disease. 

Treatment. — The  treatment  of  general  paralysis  must  be  for  the  most 
]>art  hygienic  or  symptomatic.  In  the  very  beginning  of  the  case,  whilst  the 
diagnosis  is  still  doubtful,  repeated  local  bloodletting  by  means  of  leeches 
to  the  temple,  or  the  re[)eated  use  of  the  actual  cautery  or  of  other  counter- 
irritants  to  the  nape  of  the  neck,  may  be  of  advantage.  Such  measures  are 
especially  effective  where  cortical  disease  follows  sunstroke  or  blows  upon  the 
head. 

It  is  very  doubtful  whether  drugs  have  any  direct  power  over  the  diseased 
processes,  but  corrosive  sublimate  may  be  given  in  doses  of  one-twentieth  of 
a  grain  three  times  a  day,  continued  for  many  weeks,  or  the  iodide  of  potas- 
sium, five  to  ten  grains  a  day,  may  be  substituted.  Some  alienists  have  claimed 
very  good  results  from  the  employment  of  massive  doses  of  ergot.  The  solid 
extract  should  be  employed,  and  it  may  be  given  in  doses  of  from  fifty  to  sev- 


COXSTITUTIOSAL    IXS A  DUTIES.  bbl 

enty  grains  a  day,  continued  for  many  weeks,  unless  distinct  physiological  effects 
are  produced.  For  the  relief  of  symptoms,  hyoscine,  morphine,  sulphonal,  and 
other  narcotics  may  be  used  in  times  of  wakefulness  or  excitement,  whilst  tonics 
and  laxatives  are  to  be  employed  pro  re  nata. 

The  hygienic  treatment  consists  in  the  protection  of  the  patient  by  very 
warm  clothing  and  the  administration  of  a  non-stimulating  but  abundant  and 
nutritious  diet ;  the  use  of  massage,  moderate  bathing,  careful  outdoor  exercise, 
etc.  In  all  cases  it  is  essential  that  physical  as  well  as  mental  and  emotional 
excitement  be  avoided  as  much  as  possible. 

The  treatment  of  the  latter  stages  of  the  disease  should  be  purely  hygienic 
and  symptomatic,  especial  care  being  exercised  to  see  that  the  i)atient  be  pro- 
tected from  fsecal  and  urinary  discharges,  and  that  every  precaution  be  taken 
to  prevent  decubitus.  It  is  often  necessary  to  keep  the  patient  on  a  liquid  or 
semi-liquid  diet,  as  fatal  pneumonia  from  particles  of  food  getting  into  the 
lungs  is  a  not  very  rare  occurrence. 

GROUP  IL— CONSTITUTIONAL  INSANITIES. 

The  constitutional  insanities  are  not  distinct  forms  of  disease,  but  groups 
of  symptoms  of  various  and  varying  character  which  are  the  outcome  of  con- 
stitutional vice  or  disease.  Thus  there  is  nothing  in  the  symptoms  of  a  gouty 
insanity  which  would  enable  us  to  diagnose  the  nature  of  the  case.  The  cause 
of  the  mental  aberration  in  such  a  case  can  be  recognized  only  by  recognizing 
the  presence  of  lithsemia.  The  importance  of  distinguishing  an  insanity  of  the 
present  class  lies  in  the  fact  that  relief  is  to  be  obtained  not  by  treating  the 
insanity,  but  by  treating  the  diseased  condition  which  is  the  cause  of  the 
mental  disorder. 

The  most  important  of  the  constitutional  insanities  are  the  gouty,  the  epi- 
leptic, the  hysterical,  and  the  toxa^mic. 

Gouty  Insanity. — It  is  well  known  that  gouty  paroxysms  are  frequently 
accompanied  and  preceded  by  peculiar  nervous  irritability.  At  such  times 
there  is  a  depression  of  spirits,  with  an  irritability  so  great  that  it  can  scarcely 
be  controlled  by  the  patient.  In  some  cases  these  symptoms  become  so  inten- 
sified as  almost  to  amount  to  insanity  ;  moreover,  hallucinations,  delusions,  loss 
of  mental  power — indeed,  almost  every  conceivable  manifestation  of  mental 
disorder — may  be  directly  or  indirectly  caused  by  gout.  Oarrol  in  1859  said  : 
"Gouty  mania  is  occasionally  seen;"  and  in  1875,  Dr.  P.  Berthier'  published 
a  collection  of  44  cases  of  nervous  disease  attributable  to  gout — 1  of  halluci- 
nations;  1  of  migraine;  4  of  tetanus ;  3  of  chorea  ;  1  of  hypochondria  ;  7 
of  epilepsy  ;  1  of  paralysis ;  and  26  of  mental  affections,  including  in  these 
dementia,  melancholia  with  stupor,  mania.  Althougii  in  some  of  these  cases 
the  evidence  is  not  at  all  positive  that  gout  was  the  indtcrlcs  morhi,  yet  in 
others  the  relation  seems  to  have  been  clearly  made  out. 

In  his  ])aper  read  before  the  International  Congress  at  London,  1881  (iii. 
640),  Dr.  Raynor  sujiported  the  following  conclusions: 

'  Dea  Nevrosea  diathCsiqueH,  Paris. 


558  MENTAL    DISEASES. 

1.  Protracted  ofoutv  toxferaia,  when  not  verv  intense,  nsuallv  results  in  sen- 
sory  hallucinations  or  melancholia. 

2.  Sudden  and  intense  toxaemia  results  in  mania  or  epilepsy. 

3.  Intense  and  protracted  toxaemia  usually  results  in  general  paralysis. 

4.  If  there  be  a  tendency  to  vascular  degeneration  from  plumbism,  alcohol- 
ism, etc.,  varying  degrees  of  dementia  are  produced. 

In  the  discussion  which  followed  the  reading  of  Dr.  Raynor's  paper,  Drs. 
Savage  and  Crichton  Browne  of  London  both  expressed  the  belief  that  gout 
does  cause  insanity,  the  latter,  however,  qualifying  by  the  statement,  "  only 
where  there  is  hereditary  predisposition  to  insanity." ' 

The  conclusions  of  Dr.  Raynor  are  borne  out  by  a  case  of  my  own.  A 
lady  at  regular  intervals  of  four  years  had  had  a  number  of  attacks  of  severe 
gout,  associated  with  great  depression  of  spirits,  at  times  amounting  almost  to 
pronounced  melancholia.  Finally,  at  the  end  of  four  years  of  health,  the 
patient  was  seized  with  symptoms  of  acute  dementia  or  stuporous  melancholia, 
associated  with  marked  tenderness  of  the  nerve-trunks,  and,  in  certain  por- 
tions of  the  body,  violent  neuralgia,  and  a  urine  that  was  loaded  with  uric 
acid  and  urates.  Death  occurred  after  some  weeks  from  oedema  of  the  lungs. 
At  the  autopsy  there  were  found  gouty  kidneys  and  a  remarkably  pronounced 
atheromatous  degeneration  of  the  cerebral  vessels,  the  lumina  of  some  of  the 
arteries  at  the  base  of  the  brain  being  almost  obliterated. 

Hysterical  Insanity. — The  peculiar  mental  organization  (see  p.  594) 
which  underlies  constitutional  hysteria  in  its  aggravated  forms  may  amount  to 
a  distinct  and  characteristic  pschycosis  whose  relations  with  neuropathic  insan- 
ity is  very  evident.  This  psychosis  has  been  characterized  so  vividly  and 
succinctly  by  Dr.  Folsom  that  I  quote  his  words  :  "  It  is  characterized  by 
extreme  and  rapid  mobility  of  the  mental  symptoms — amnesia,  exhilaration, 
melancholic  depression,  theatrical  display,  suspicion,  distrust,  prejudice,  a  curi- 
ous combination  of  truth  and  more  or  less  unconscious  deception,  with  periods 
of  mental  clearness  and  sound  judgment  which  are  often  of  greater  degree  than 
is  common  in  their  families ;  sleeplessness,  distressing  and  grotesque  halluci- 
nations of  sight,  distortion  and  perversion  of  facts  rather  than  definite  delusions, 
visions,  hyperaesthesias,  anaesthesias,  paraesthesias ;  exceeding  sensitiveness  to 
light,  touch,  and  sound  ;  morbid  attachments,  fanciful  beliefs,  an  unhealthy 
imagination  ;  abortive  or  sensational  suicidal  manoeuvres,  occasional  outbursts 
of  violence  ;  a  curious  combination  of  unspeakable  wretchedness  alternating 
with  joy,  generosity,  and  selfishness, — of  gifts  and  graces  on  the  one  hand  and 
exactions  on  the  other.  The  mental  instability  is  like  a  vane  veered  by  every 
zephyr.  The  most  trifling  causes  start  a  mental  whirlwind.  There  is  no  dis- 
ease giving  rise  to  more  genuine  suffering  or  appealing  more  strongly  for  sym- 
pathy. Yet  when  this  is  freely  given  it  does  harm.  One  such  person  in  the 
house  wears  out  and  outlives  one  after  another  every  healthy  member  of  the 
family  who  is  unwisely  allowed  to  devote  herself  with  conscientious  zeal  to  the 
invalid." 

'  For  diHCUssion  of  Epileptic  Insanity  see  tlie  urticle  on  Epilepsy,  page  617. 


TOXyEMIC  IXSANITTES.  559 

In  nature  the  mildest  hysteria  grades  without  break  in  the  series  into  the 
most  severe,  and  the  difficulty  is  to  decide  when  hysteria  has  crossed  the  line 
that  separates  responsibility  from  irresponsibility  ;  bnt  certainly  in  some  cases 
of  hysteria  the  mental  symptoms  are  sufficient  to  indicate  restraint.  Further, 
in  some  cases  of  hysteria  an  acute  mania  or  a  peculiar  automatism  with  loss  of 
conscious  self-control  may  occur.     (See  page  594.) 

Toxemic  Insanities. 

The  only  insanities  of  the  present  class  requiring  notice  here  are  those 
springing  fi-om  the  abuse  of  alcohol.  Such  mental  disturbances  may  be 
divided  into  the  subacute  and  chronic  forms,  to  which  the  names  delirium 
tremens  and  alcoholic  insanity  may  be  assigned. 

Delirium  Tremens. — Delirium  tremens  is  a  peculiar  series  of  acute  symp- 
toms which  are  produced  by  excessive  drinking.  The  affi^ction  is  especially  apt 
to  develop  upon  the  sudden  cessation  in  the  use  of  the  stimulants,  but  may  come 
on  during  the  debauch.  In  their  mildest  form  the  symptoms  constitute  that 
condition  known  by  old  drunkards  as  "  the  horrors,"  in  which  the  sleep  is  dis- 
turbed, the  hand  tremulous,  the  mind  weak  and  confused,  and  the  patient 
troubled  with  frightful  imaginings,  vague  alarms,  and  an  apparently  causeless 
depression  of  spirits.  When  the  attack  is  more  severe,  hallucinations  of  sight, 
of  hearing,  and,  more  rarely,  of  touch,  occur.  These  hallucinations  always  have 
in  them  an  element  of  terror  or  of  horror.  Disgusting  objects,  such  as  snakes, 
toads,  rats,  and  mice,  and  similar  unclean  creatures,  crawl  over  the  bed  or  the 
person.  Voices  predicting  evil  or  bringing  messages  of  remorse  or  uttering 
threats  of  punishment  are  heard.  The  patient  may  seem  violent,  and  may  even 
attack  his  attendants,  but  the  violence  is  that  of  terror,  and  not  of  aggression. 
The  attack  is  an  attempt  at  defence.  There  is  great  insomnia,  and  usually 
when  the  patient  can  be  made  to  sleep  the  mind  is  clear  after  the  awakening. 
This  is  not,  however,  invariably  the  case. 

I  have  seen  delirium  tremens  gradually  pass  through  successive  days  of 
wakefulness  and  nights  of  sleeping  into  a  chronic  mania  not  readily  to  be  dis- 
tinguished from  that  arising  from  other  causes.  In  the  earlier  attacks  of 
delirium  tremens  occurring  in  very  robust  people,  when  all  the  mucous  mem- 
branes are  irritated,  and  when  probably  there  is  direct  irritation  of  tiie  brain 
and  its  meninges,  there  may  be  a  slight  febrile  reaction  and  even  a  strong  and 
excited  pulse ;  bnt  the  disease  is  typically  asthenic,  with  loss  of  muscular 
])ower,  tremulonsness,  and  rapid,  feeble  pulse,  and  when  death  occurs  it  is 
from    exhaustion.     Canliac    failure   is   in   such    cases   always    to   be   guarded 

against. 

Sometimes  the  patient  suiTcring  from  dcliriuui  ticuiens  has  sufficient  ration- 
ality to  receive  his  physician  with  a  quiet,  gentle  com-tesy  and  to  answer  ques- 
tions without  irritation.  It  will  l)e  noted,  however,  that  he  is  evidently  pre- 
occupied, and  that  occasionidly  lie  turns  his  Ih;i<I  <»r  casts  furtive  glances  from 
one  part  of  the  apartment  to  the  other  ;  mihI  :i  litth-  linesse  will  reveal  the  fact 


560  MENTAL    DISEASES. 

that  during  the  whole  time  he  is  seeing  visions  or  hearing  sounds,  or  is  at  least 
laboring  under  a  profound  apprehension  of  attack. 

Diagnosis. — The  diagnosis  of  delirium  tremens  is  usually  easy,  even  when 
the  history  of  the  case  is  not  clear.  The  peculiar  terror  underlying  all  the 
delusions,  hallucinations,  and  attempts  at  violence  is  characteristic,  as  is  also 
the  tremulousness  of  the  hands  when  extended.  When  pneumonia  occurs 
during  a  period  of  delirium  tremens  the  type  of  the  delirium  may  change, 
tremors  may  be  lost,  and  the  patient  may  become  so  violently  aggressive  as  to 
lead  to  a  mistaken  diagnosis. 

Treatment. — In  the  treatment  of  delirium  tremens  the  first  indication  is 
for  restraint  to  prevent  injury  by  the  patient  to  himself  or  to  others.  Freedom 
in  a  well-padded  room  may  be  allowed,  but  in  the  majority  of  cases  such  a 
room  is  not  available,  and  properly-constructed  straps  securing  the  person  in 
bed  are,  in  a  violent  case,  much  better  than  restraint  by  means  of  nurses,  the 
strap  exciting  less  of  antagonism  than  does  an  attendant,  and  being  more 
steady  and  certain  in  its  restraint.  The  second  indication  is  for  the  support 
of  the  svstem  by  means  of  highly  nutritious  and  stimulating  food.  Milk, 
strong  soups  or  beef  essence  with  eggs  stirred  into  them  just  as  they  have 
ceased  boiling,  and  similar  liquids  usually  constitute  the  best  articles  of  diet. 
As  the  digestion  is  in  these  cases  often  deranged,  it  is  essential  for  the  practi- 
tioner to  remember  that  the  food  which  nourishes  is  not  that  whi^h  enters  the 
stomach,  but  that  which  is  digested ;  so  that  the  eifort  should  be  by  frequently 
repeated  small  portions  of  nutriment  to  get  as  much  material  worked  upas 
possible.  Again,  the  mucous  membrane,  which  has  been  accustomed  to  the 
local  effects  of  alcohol,  is  often  simply  beneficially  stimulated  by  amounts  of 
red  pepper  and  other  spices  which  would  produce  gastritis  in  a  normal 
stomach ;  hence,  even  though  the  stomach  of  the  drunkard  be  inflamed, 
highly-seasoned  food  is  usually  of  great  service.  The  limit  of  the  amount  of 
food  given  in  these  cases  should  be  the  limit  of  possible  digestion. 

In  the  medical  treatment  of  delirium  tremens  the  first  indication  is  in  most 
cases  to  relieve  abdominal  engorgement  and  to  remove  eifete  materials  from 
the  system.  Very  frequently  the  best  practice  is  to  begin  by  the  exhibition 
of  three  grains  of  ipecacuanha  in  pill  form  every  fifteen  minutes  until  free 
vomiting  is  produced,  and  even  if  the  patient  be  suffering  from  excessive 
nausea  and  vomiting,  this  practice  is  often  of  service.  On  the  other  hand, 
when  great  feebleness  exists  the  use  of  such  an  emetic  may  be  improper. 
After  the  ipecacuanha  has  acted  a  grain  of  calomel  may  be  given  every  hour 
until  free  purgation  is  induced,  and  not  rarely  an  effervescent  mixture  con- 
taining citrate  of  potassium  is  very  useful  in  acting  as  a  depurant  through 
the  kidneys.  Again,  profuse  sweating  produced  by  pilocarpine  or  the  hot 
bath  may  sometimes  be  useful,  and  there  are  robust  cases  which  can  be 
successfully  treated  by  veratrum  viride,  in  repeated  doses  until  vomiting 
results. 

The  second  indication  for  medical  treatment  is  to  quiet  nervous  excitement. 
For  this  purpose  the  bromides  and  the  hydrobromate  of  hyoscine  must  be  relied 


TOXEMIC  INSANITIES.  561 

upon.  These  drugs  should  be  given,  steadily  day  and  night  at  regular  inter- 
vals, the  hyoscine  being  withdrawn  if  it  be  found  in  any  way  to  disagree  with 
the  patient. 

The  third  indication  is  to  produce  sleep.  For  this  purpose  various  hyp- 
notics have  been  used.  Sulphonal  may  be  employed  ;  paraldehyde  has  been 
exiiibited ;  but  the  combination  of  chloral  and  sulphate  of  morphine  far 
exceeds  in  efficiency  and  general  applicability  all  other  hypnotics.  The  chloral 
(fifteen  to  twenty  grains)  and  morphine  (grain  one-quarter  to  one-third)  may 
be  exhibited  at  bedtime,  and  repeated  in  half-doses  at  intervals  of  an  hour,  pro 
re  nata,  care  being  exercised  not  to  overdo  the  exhibition  of  narcotics. 

The  fourth  indication  is  to  support  the  system  by  means  of  stimulants. 
One  of  the  most  important  questions  to  be  decided  is  as  to  the  necessity  of 
using;  alcoholic  drinks.  In  manv  cases  of  delirium  tremens  alcohol  does  harm 
rather  than  good,  and  in  the  majority  of  cases  its  use  is  not  essential.  The 
moral  reasons  against  its  employment  are  very  strong,  and  therefore  commonly 
it  is  not  wise  to  use  it.  On  the  otiier  hand,  in  feeble  subjects  or  in  old  alco- 
holics the  exhibition  of  alcohol  in  some  form  or  other  may  be  necessary  to  the 
saving  of  life.  In  many  cases  of  delirium  tremens  strychnine  is  serviceable 
as  a  stimulant,  but  when  there  is  any  fear  of  cardiac  failure  digitalis  is  the 
most  reliable  of  all  remedies.  It  must  be  given  in  very  large  doses,  and 
usually  enormous  amounts  are  well  borne.  Various  clinicians  have  claimed 
vcrv  Kood  results  from  the  exhibition  of  half-ounce  doses  of  the  tincture,  but 
it  seems  to  me  that  a  safer  method  is  to  give  from  ten  to  twenty  minims  at 
intervals  of  from  two  to  four  hours,  watching  closely  the  effect,  and  with- 
drawing the  remedy  as  soon  as  any  evidence  of  the  digitalis  pulse  can  be 
perceived. 

Alcoholic  Insanity. — The  prolonged  use  of  alcohol  may  lead  to  a  grad- 
ually increasing  functional  disturbance  of  the  nervous  system,  ending  it  may  be 
in  structural  chancre.  Under  the  continuous  influence  of  the  narcotic  the  brain 
j)orforms  its  functions  slowly  and  imj)crfectly  and  the  mental  movements 
become  sluggish  and  weak  ;  the  memory  is  greatly  impaired  ;  the  power  of 
fixing  the  attention  steadily  diminislies,  but  the  intellectual  weakness  is  espe- 
cially shown  by  the  lessening  of  tiie  power  of  the  will,  so  that  not  only  is  the 
judgment  uncertain,  but  its  dictates  are  not  carried  out.  There  is  also  a  dis- 
tinct tendency  to  emotional  depression,  and  often  a  peculiar  suspiciousness 
which  is  the  groundwork  for  delusions.  A  step  farther,  and  hallucinations 
haunt  the  victim.  The  route  to  insanity  and  irresponsibility  from  this  con- 
dition is  short.  Out  of  such  a  state  is  easily  developed  the  most  characteristic 
and  frequent  forin  of  alcoholic  insanity — namely,  that  with  depressive  delu- 
sions. In  some  cases  this  variety  of  alcoholic  iusanitv  ai)pcars  suddcnlv  with 
sym])toms  for  a  time  not  to  be  distinguished  ri(»m  delirium  tremens.  Indeed, 
I  think  it  perfectly  correct  to  say  that  a  patient  may  pass  from  delirium 
tremens  into  alcoholic  iusanity. 

It  is  affirmed  that  headache  and  other  symptoms  of  sudden  congestion  of  the 
brain  especially  usher  in  the  attack  of  alcoholic  insanity.     When  the  symptoms 
Vol.  r.— ;ifi 


562  MENTAL    DISEASES. 

are  active,  hallucinations^  are  very  numerous,  constantly  changing,  and  almost 
always  are  such  as  to  inspire  terror  or  disgust.  In  a  very  short  time  they  are 
accompanied  by  delusions  of  persecution  :  voices  of  reproach,  threatening,  or 
remorse,  mocking  faces,  unclean  beasts,  tormenting  devils, — these  and  similar 
visions  drive  the  victims  into  profound  melancholy,  and  finally  may  lead  to 
suicide  or  murder.  According  to  Spitzka,  the  delusions  of  chronic  alcoholism 
almost  always  relate  to  the  sexual  organs,  to  the  sexual  relations,  or  to  poisoning. 
Underlying  this  variety  of  alcoholic  mania  is  frequently  an  intense  fear  which 
may  lead  to  violence,  as  when  a  man  kills  his  wife  because  he  fears  that  she  will 
poison  him.  Not  uncommonly  the  depressive  sexual  delusion  leads  to  an  out- 
burst of  uncontrollable  jealousy  and  rage,  so  that  wife-murder  from  motives 
of  jealousy  is  not  a  rare  result  of  alcoholic  mania.  There  is  in  some  of  these 
cases  a  very  marked  relation  between  the  presence  of  alcohol  in  the  blood  and 
the  insane  outburst.  The  maniacal  drunkard  may  be,  when  not  under  the 
influence  of  the  poison,  fairly  rational,  but  is  converted  by  alcohol  into  a 
wild  beast,  although  he  has  few  or  none  of  the  ordinary  symptoms  of  intoxi- 
cation. The  man  may  walk  straight  and  talk  rationally  on  general  subjects, 
but  be  profoundly  under  the  influence  of  a  depressive  or  persecutive  delu- 
sion which  disappears  when  the  blood   is   freed  from  alcohol. 

The  relation  between  depressive  alcoholic  insanity  and  mania  a  potu  is, 
as  has  been  already  stated,  very  close.  Insomnia,  emotional  excitement,  espe- 
cially connected  with  fear,  hallucinations,  and  delusions,  are  common  to  each  ; 
but  the  tremors  are  more  marked  in  delirium  tremens,  and  when  an  attack  of 
alcoholic  insanity  is  acute  and  tremors  are  pronounced  it  may  be  considered  to 
be  mania  a  potu. 

Dr.  F.  Lentz^  calls  attention  to  a  form  of  alcoholic  insanity  with  expansive 
delusions  and  hallucinations  of  sight  and  hearing,  which,  very  strangely,  in 
most  instances  relate  to  God  and  a  future  state.  Visions  of  supernatural 
beings,  and  esj)ecially  of  the  Deity  bathed  in  an  aureola  of  light,  perpetually 
delight  the  patient ;  the  ministrations  of  angels  seem  to  bring  relief,  or  may- 
hap the  voice  of  God  himself  is  heard  in  command  or  instruction. 

It  would  appear  that  two  forms  of  alcoholic  insanity  must  be  recognized — 
one  a  lypomania,  or  melancholia  with  delusions  of  persecution;  the  other  a 
megalomania,  with  a  strong  tendency  to  religious  hallucinations. 


GROUP   III.— PURE   INSANITIES. 

Melancholia. 

Definition. — An  acute  or  chronic  pure  insanity,  characterized  by  the  domi- 
nance of  depressive  emotions. 

Melancholia  usually  comes  on  gradually,  with  insomnia,  increasing  depres- 

'  Spitzka  says  they  are  usually  of  vision:  Dr.  F.  Lentz  (De  V Alcoholvime)  says  that  they  are 
almost  exclusively  of  hearing:  my  experience  is  that  both  forms  of  hallucination  are  frequent. 
'■'  Op.  dl.,  p.  491. 


JfJJLA  XCIIOL I A .  r){V?y 

sion  of  spirits,  malaise,  failure  of  digestion,  and  often  a  whole  range  of  minor 
nervous  disturbances  similar  to  those  of  an  ordinary  neurasthenia. 

The  basis  of  the  fully-formed  disease  is  a  psychical  anguish  or  depression, 
manifesting  itself  on  all  occasions  and  dominating  all  the  life.  It  does  not 
diifer  save  in  its  intensity  from  emotional  depression  in  health  resulting  from 
profound  grief  or  other  sufficient  cause.  It  is  only,  after  all,  a  multiplied 
exaggeration  of  a  mood,  but  it  affects  all  cerebration.  Through  it  the  whole 
outside  world  is  hung  in  black,  and  every  perception  of  this  world  is  painful 
(psychical  di/sthe.sia),  or  all  perceptions  are  flattened  down  by  the  absence  of 
desire  and  are  scarcely  felt  by  the  consciousness  (psychical  anaesthesia),  or 
mental  acts  or  perceptions  cause  intense  disgust  (^psychical  hyperesthesia). 

During  all  of  this  time  there  may  be  no  loss  of  reasoning  power,  no  true 
intellectual  insanity.  The  patient  fails  to  be  interested  in  tiie  life  around  him, 
not  because  he  is  incapable  of  understanding  the  problems  of  life,  but  because 
nothing  but  himself  is  of  interest  to  him  or  occupies  his  thoughts,  or  perchance 
because  all  other  things  fill  him  with  disgust,  and  the  mere  effort  to  drag  awav 
his  attention  from  his  ow'n  feelings  gives  to  him  great  pain  (psychical  hyper- 
o'sthesia).  In  the  lighter  degrees  of  the  affection  the  patient  will  simply  say 
that  he  is  horribly  depressed  and  cares  for  nothing.  With  the  apathetic  total 
lack  of  energy  so  characteristic  of  the  disease,  the  subject  sits  all  day  in  a  chair, 
quiet,  perhaps  with  the  hands  folded,  seemingly  thinking  of  nothing,  with  an 
expression  of  perfect  indifference  and  apathy  on  his  countenance.  There  is  no 
interest  in  business,  in  wife,  or  family,  not  because  the  relations  are  not  recog- 
nized, but  because  the  man  is  absorbed  in  his  own  woe,  and  is  paralyzed  by 
the  psychical  pain  that  attends  any  effort. 

When  the  symptoms  are  more  active  and  severe,  instead  of  simple  apathy 
there  is  wringing  of  the  hands  and  perpetual  moaning  and  lamentation,  not 
for  any  definite  reason  that  the  patient  can  assign,  but  simply  because  of  the 
<le})ression  of  spirits.  Under  these  circumstances  it  will  be  found  that  all  his 
thoughts  are  tinctured  with  this  emotional  depression.  If  the  man  be  a  busi- 
ness-man, he  sees  nothing  but  ruin  before  him.  If  he  have  a  conscience  which 
is  not  void  of  offence,  the  memory  of  his  past  misdeeds,  like  a  Nemesis,  for 
ever  haunts  him.  If  his  children  are  ill,  they  are  going  to  be  swept  away  by 
death.  Tiie  whole  landscape  is  covered  with  a  black  cloud,  which  throws 
everything  into  the  darkest  shadow.  Nevertheless,  there  may  be  even  yet  no 
intellectual  delusions.  When  the  patient  is  aroused  he  talks  well  and  reasons 
well.  If  you  can  get  him  to  forget  himself  for  a  moment,  his  intellectual 
actions  are  perfect.  After  a  time  delusions  make  their  appearance.  They 
arc  in  typical  cases  always  unsystematized.  They  usually  develop  gi-adually, 
and  not  rarely  are  the  outcome  of  some  real  feeling  which  the  patient  has. 
They  may  exist  \\ith  or  without  hallucinations.  Uoth  halhicinations  and 
delusions  always  take  tlu;  depressive  type.  IlaUuciiiations  of  hearing  are 
the  most  frequent.  Tiio  patient  hears  voices,  but  they  are  evil  voices.  Those 
who  have  committed  mur<ler  have  sometimes  asserted  that  they  had  two  voices 
in  them,  one  crying,  *'  Kill  !  kill  !"  the  ' 'her  voice  trying  to  restrain  them. 


564  MENTAL    DISEASES. 

Men  have  held  their  hands  in  the  fire  until  they  were  burnt  black  because 
they  have  heard  voices  telling  them  that  it  was  better  to  enter  into  the  next 
world  maimed  than  to  go  with  a  whole  hand  guihy  of  blood  or  other  offence. 

Sometimes  hallucinations  of  sight  occur,  but  these  are  less  common  than 
hallucinations  of  hearing.  Troops  of  spirits  from  the  other  world  pass  before 
the  patient — never  angels  or  spirits  from  heaven,  but  always  demons  of  sorrow 
and  of  woe. 

Delusions  of  touch  are  rare,  and  delusions  of  smell  are  still  more  uncom- 
mon. I  do  not  recall  a  case  in  which  I  have  seen  a  patient  with  delusions  of 
smell.  They,  however,  are  occasionally  present.  The  melancholic  never  smell 
pleasant  odors.  It  is  always  sulphurous  vapors  or  horridly  foetid  exhalations 
that  oppress  them. 

The  sensory  disturbances  of  melancholia  are  distinct  and  sometimes  severe. 
Headache  may  be  among  the  prodromes,  but  usually  the  complaint  is  not  so 
much  of  distinct  true  headache  as  of  indescribable  distress,  a  sense  of  empti- 
ness or  of  pressure  or  of  some  other  parsesthesia  in  the  head.  In  the  height 
of  the  disease  parsesthesia,  more  or  less  widespread,  or  partial  anaesthesia,  ir- 
regular hypersethesia,  and  neuralgia,  are  often  present.  The  most  intense  suffer- 
ings of  melancholia  are  those  produced  by  a  peculiar  horrible  distress  referred 
to  the  upper  chest,  and  commonly  known  as  "  praecordial  anguish."  This 
appears  to  be  simply  an  exaggeration  of  the  cardiac  distress  sometimes  pro- 
duced in  normal  life  by  sudden  and  overpowering  sorrow.  Especially  frequent 
in  the  morning  hours,  it  may  occur  at  any  time  of  day,  and,  whilst  usually 
paroxysmal,  may  continue  for  a  length  of  time.  The  attacks  usually  come 
on  suddenly,  and  rapidly  reach  their  height  until  perchance  the  agony  and 
its  accompanying  terror  so  dominate  the  consciousness  that  it  is  obscured  or 
lost  in  the  wild  delirium  in  which,  with  blind  disregard  of  himself  and  others, 
the  patient  convulsively  attacks  and  destroys  all  within  his  reach — stripping 
iiimself  or  herself  naked,  breaking,  mashing,  cutting,  tearing,  even  perchance 
disembowelling  himself  or  twisting  off  the  genitalia.  Self-mutilation,  murder, 
suicide,  utter  destruction  of  sensate  and  insensate  objects, — these  are  the  not 
infrequent  outcomes  of  a  despairing  fury  inspired  by  agony  and  unutterable 
terror  {raptxis  melancholicufi). 

During  a  paroxysm  of  psychical  anguish  the  respiration  is  usually  rapid 
and  superficial  ;  the  heart's  action  quick,  irregular,  with  small,  thready  pulse  ; 
the  skin  cool  and  white:  not  rarely  the  paroxysms  end  abruptly  with  a  pro- 
fuse sweat — facts  which  have  given  origin  to  the  belief  that  the  praecordial 
anguish  is  a  neurosis  of  the  sympathetic  system. 

In  melancholia  the  sexual  function  is  usually  very  much  depressed,  often 
for  a  time  being  set  aside.  In  the  female,  at  the  menstrual  period,  the  gen- 
eral symptoms  are  apt  to  be  worse,  and  liysterical  nervous  disturbances  are 
not  uncommon.  Even  early  in  the  disorder  sleep  is  broken,  unrefreshing, 
disturbed  by  horrible  dreams  or  veritable  visions  of  terror,  and  during  the 
height  of  the  disease  it  is  often  almost  altogether  put  aside.  The  physical 
health  and  the  general  nutrition  are  always  lowered,  the  tongue  coated,  the 


MELA  NCHOLIA .  565 

breath  heavy  or  perhaps  very  foul,  the  appetite  almost  or  completely  want- 
ing, or  replaced,  it  may  be,  by  an  absolute  loathing  for  food.  The  urine  is 
scanty,  heavily  loaded  with  urates,  oxalates,  or  phosphates ;  the  muscular 
system  relaxed,  the  desire  for  and  indeed  almost  all  power  of  exertion  being 
lost.  In  severe  cases  progressive  emaciation  may  go  on  rapidly  to  great  wast- 
ing, accompanied  by  subnormal  temperature,  dry  and  harsh  or  clammy  and 
cold  skin,  and  cold  cyanotic  extremities. 

Cases  of  melancholia  seem  to  naturally  group  themselves  into  melancholia 
simplex  (simple  melancholia),  melancholia  attonita  (melancholy  with  stupor), 
and  melanciiolia  agitata  (melancholy  with   motor  excitement). 

The  cases  of  simple  melancholia  are  divided  by  Krafft-Ebing  into — 

First,  melancholia  without  delirium,  which  includes  those  cases  of  melan- 
cholia which  are  not  accompanied  by  intellectual  insanity — cases  which  are 
usually  associated  with  neurastheuia,  hysteria,  hypochondriasis,  and  similar 
affections,  which  are  often  called  forth  and  called  into  being  by  untoward  cir- 
cumstances acting  upon  a  neuropathic  subject.  Among  the  millions  of  men 
gathered  into  the  American  armies  in  the  late  war  mild  melancholia,  the  result 
of  nostalgia  or  homesickness  (not  of  cowardice),  amounted  in  some  cases  to  a 
true  insanity. 

Second,  melancholia  with  precordial  anguish. 

Third,  melancholia  with  delusions  and  hallucinations. 

Fourth,  melancholia  religiosa,  in  which  the  delusions  lead  the  subject  to 
iielieve  that  he  is  deserted  by  God,  and  that  through  eternity  he  shall  suffer 
the  pangs  of  damnation  ;  or  perhaps  convince  him  that  he  is  already  pos- 
sessed with  devils  (melancholia  clemoniaca). 

Fifth,  melancholia  hypochondria,  with  hypochondriacal  delusions.  In  a 
large  proportion  of  the  cases  the  delusions  are  connected  with  the  sexual 
organs.  This  form  of  melancholia  shades  by  insensible  degrees  into  h)/po- 
chondriasis — i.  e.  that  condition  in  which  the  subject  centres  all  his  thoughts 
upon  his  own  health  and  grossly  exaggerates  his  own  symptoms,  or  periiaps 
imagines  svmptoms  which  do  not  exist.  Hypochondriasis  by  insensible 
decrrees  ao-ain  <rrades  into  the  natural  state  through  a  series  of  cases  in 
whirh  there  are  various  degrees  of  excessive  solicitude  concerning  health. 

Melancholia    Attonita  (melancholia  with  stupor.)' — This   is  a  very 

'  The  fcntntonin  of  Dr.  Kalilhaum,  which  by  some  :uithoriti&s  is  believed  to  be  a  distinct 
insanity,  is  thus  delined  by  ^^l)itzka : 

"  Katatonia  is  a  form  of  insanity  characterized  by  a  pathetical  emotional  sUite  and  verbige- 
ration, combined  with  a  condition  of  motor  tension. 

"The  illness  bofjins  witii  :m  initial  sta{,'c  rescniljling  that  of  an  ordinary  melancholia.  This 
is  followed  by  a  period  in  which  the  patient  presents  an  almost  cyclical  alternation  of  atony, 
excitement  of  a  i)eculiar  type,  confusion,  and  dei)ress,ion,  wliicli  finally  merges  into  a  state  of 
mental  weakness  approaching,  if  not  reaching,  the  degree  of  a  terminal  dementia.  Any  single 
one  of  these  enunu'rated  jihascs  may  be  absent. 

"  The  excited  sta^c  jircsents  symptoms  of  a  kind  dillerent  from  those  of  ordinary  melancholia, 
and  .onstitutes  a  coimcclitig  link,  as  it  were,  between  the  symptoms  of  an  agitated  melancholiac 
and  those  of  a  limatic  willi  fixed  delusions.  Some  of  tiie  patients  present  exaggerated,  others 
diminished,  self-esteem,  and  not  rarely  does  the  developing  <ielirium  assume  an  exj)ansive  tinge. 


566  MENTAL    DISEASES. 

severe  form  of  melancholia,  in  whicii  the  patient  passes  the  time  in  a  con- 
dition of  partial  or  even  complete  stupor,  seemingly  motionless  and  emotion- 
less. In  extreme  cases  the  mental  condition  can  scarcely  be  distinguished 
from  that  of  primary  dementia :  the  cerebral  power  seems  to  be  completely 
abolished.  The  careful  observer  can,  however,  usually  distinguish  this  state 
from  that  of  primary  dementia  by  noticing  an  occasional  anxious  look,  a  wrink- 
lino-  of  the  forehead  or  other  muscular  contraction,  which  shows  that  the  indi- 
vidua)  has  still  some  power  of  thought  or  perception.  The  two  states  are  also 
separated  by  the  fact  that  the  melancholiac  after  recovery  has  some  memory 
of  events  which  have  happened  during  this  condition  of  stupor. 

In  melancholia  with  stupor  mild  muscular  contractures,  and  especially 
marked  rigidity  of  the  muscles,  are  common.  In  some  cases  there  is  distinct 
catalepsy.  Sensation  may  be  normal,  but  there  may  be  either  anaesthesia  or 
hvperaesthesia.  The  quick,  small  pulse,  the  dry,  harsh  skin,  the  aged  expression 
of  the  face,  the  slow  superficial  respiration,  the  subnormal  temperature,  the 
general  failing  secretions  (including  menstruation),  the  loss  of  digestive  power, 
the  tendency  to  emaciation, — all  these  are  but  the  evidences  of  the  general 
depression  of  the  functions  and  of  nutrition  which  is  so  marked  in  this  form 
of  melancholia. 

Melancholia  Agitata  is  that  variety  in  which  there  is  great  excite- 
ment, the  patient  being  continually  on  the  move,  rushing  up  and  down, 
lamenting  loudly,  wringing  the  hands,  tearing  the  hair,  destroying  his  clothes, 
etc.  The  agitation  may  rise  to  the  point  of  complete  frenzy.  The  melan- 
cholic frenzy  differs  from  that  of  mania  in  being  founded  upon  a  state  of 
intense  terror  and  fear. 

Melancholia  may  pursue  an  acute,  subacute,  or  chronic  course.  In  even 
the  most  acute  cases  many  weeks  are  required  for  recovery,  the  subacute  con- 
tinuing many  months,  the  chronic  many  years.  The  recovery  is  usually  grad- 
ual, but  I  have  seen  sudden  recovery  after  sixteen  years'  illness.  Remissions 
are  common.  About  60  per  cent,  of  the  cases  get  well,  the  proportion  being 
much   larger  in  the  mild  cases  and   much  less  in  melancholia  with  stupor. 

But  all  Uatatonics  exhibit  a  peculiar  pathos,  either  in  the  direction  of  declamatory  gestures  and 
theatriciil  behavior  or  of  an  ecstatic  religious  exaltation.  Frequently  the  patients  wander  about 
imitating  great  actors  or  preachers,  and  often  express  a  desire  and  take  steps  to  become  such 
preachers  and  actors." 

The  hallucinations  of  katatonia  are  always  depressive  and  accompanied  by  a  melancholic 
depression  of  spirits,  wliich  is  said,  however,  never  to  be  so  painful  as  in  melancholia.  Severe 
occipital  headaclie  and  catalei)toid  attacks  are  asserted  to  be  characteristic.  Tlie  cataleptoid 
condition  is  typical  and  extreme,  the  patient  remaining  for  long  periods  corpse-like  and  immo- 
bile. I  have  seen  two  cases  which  perhaps  ought  to  be  classed  as  katatonia.  Whilst  under 
observation  there  was  no  headache  and  no  period  of  excitement,  but  the  cataleptoid  condition 
was  very  marked.  For  hours  the  j)atient  would  remain  standing  or  sitting,  perfectly  immobile 
in  whatever  position  he  might  be  ]ilaced.  Certain  forms  of  melancholia  attonita  (melan- 
cholia agitata)  resemble  katatonlc  insanity,  and  the  line  of  separation  seems  a  very  uncer- 
tain one.  Masturbation  is  idleged  to  be  frequent  in  katatonia,  and  was  markedly  present  in 
one  of  my  cases.  It  is,  however,  very  common  in  all  classes  of  mental  weakness  approaching 
dementia. 


MAiXIA.  567 

Death  may  take  place  from  tuberculosis,  colliquative  diarrhoea,  or  other  compli- 
«\tions,  and  a  small  percentage  of  the  cases  end  in  terminal  dementia. 

Treatment. — In  the  treatment  of  melancholia  the  first  indication  is  to 
obtain,  as  far  as  possible,  bodily  and  mental  rest.  Ariruino;  with  the  person, 
attempting  to  convince  him  of  the  wisdom  of  overcoming  his  feelings  and 
delusions,  are  usually  worse  tlian  useless:  the  attempt  should  be  to  divert  his 
thoughts  to  other  objects.  When  they  can  be  carried  out  without  too  nuich 
friction,  rest  in  bed,  with  massage,  electricity,  and  the  other  concomitants  of 
the  so-called  "  rest-cure  "  are  important.  The  second  indication  is  the  main- 
tenance of  the  bodily  power  by  means  of  properly  regulated  tonics  and  as 
nutritious  a  diet  as  can  be  obtained.  In  many  cases  forced  feeding  is  essen- 
tial. Tiie  third  indication  is  the  cure  as  rapidly  as  may  be  of  any  existing 
disease,  since  melancholia  may  originate  in  or  be  kept  up  by  gastro-intes- 
tinal  catarrh,  liEemorrhoids,  or  other  abdominal  disease.  The  fourth  indi- 
cation is  to  subdue  nervous  excitement,  and  to  procure  sleep  by  the  use  of 
carefully-selected  narcotics.  If  there  be  much  excitement  during  the  day, 
hydrobromate  of  hyoscine,  in  doses  of  the  one-eightieth  to  the  one-hun- 
dred-and-twentieth  of  a  grain,  at  eight  to  twelve  hours'  interval,  often  acts 
most  haj)i)ily.  At  night  chloral  may  be  used  with  much  certainty  of  action, 
but  I  think  its  continued  use  is  more  detrimental  than  that  of  sulplional  or 
even  of  opium.  In  some  cases  of  melancholia  the  use  of  opium  in  the  form 
of  the  extract,  at  regular  intervals  of  six  to  eight  hours,  acts  most  happily. 
Prolonged  warm  baths,  or,  better  still,  hot  packs,  are  from  time  to  time  of 
great  service  in  quieting  agitation  and  producing  sleep.  Beer  or  other  alco- 
Jiolic  drinks  may  sometimes  be  given  with  advantage  as  narcotic  stimulants, 
but  the  moral  danger  of  their  use  must  not  be  forgotten.  In  all  cases  of 
melancholia  great  watchfulness  against  sudden  destructive  suicidal  or  homi- 
cidal outbreaks  is  essential,  as  it  is  impossible  to  foretell  with  absolute  cer- 
tainty even  in  mild  melancholia  what  will  hapj)en  in  the  next  few  hours. 

Mania. 

Definition. — A  mental  condition  in  which  there  is  great  emotional  exalta- 
tion dominating  the  individual,  and  accompanied  with  a  greater  or  less  degree 
of  mental  aberration. 

Acute  mania  is  sometimes  developed  with  great  suddenness;  more  often  it 
is  preceded  by  a  prodromic  stage  of  emotional  depression.  The  depressive 
stage  may  last  from  a  few  days  to  tin-ee  months.  Tiicre  is  often  a  sense  of 
lassitude,  with  inability  or  disinclination  to  work,  a  lack  of  the  usual  power 
of  fixing  the  attention,  depression  of  spirits,  and  a  feeling  of  unrest  which 
causes  the  subject  to  worry  perpetually  al)out  himself;  tlu;  bowels  are  costive, 
the  appetite  is  poor,  and  dysjK'ptic  symj)toms  are  often  troublesome.  The 
resemblance  of  this  ctrndition  to  a  mild  melancholia  is  so  close  that  it  is  fre- 
quently spoken  of  as  the  melancliolic  stugc  of  mania.  Usually,  after  a  time, 
the  subject  gradually  returns  to  his  ii(.riii:d  state,  except  perhaps  tliat  his  per- 
ceptions are  abnormally  quick  ami   that    lie  is  abnormally  happy  or  even  gay. 


568  MENTAL    DISEASES. 

Rapidly  now  the  emotional  excitement  rises,  delusions  and  hallucinations 
appear,  and  the  maniacal  stage  is  reached.  When  the  affection  as  at  its 
height  its  victim  raves  incessantly,  shouting  out  a  perpetual  stream  of  inco- 
lierent  threatenings,  revilings,  obscenities,  and  blasphemies.  With  a  pro- 
digious and  untiring  strength  he  rushes  about  his  apartment,  struggles  with 
his  attendants  or  his  mechanical  restraints,  tears  into  shreds  whatever  clothing 
he  can  lay  his  hands  upon,  destroys  all  about  him  that  is  breakable,  smears 
his  excrement  over  his  person  and  surroundings,  and  so  passes  whole  days  and 
nights  in  unceasing  fury.  The  insomnia  is  almost  complete,  and  if  for  brief 
intervals  sleep  comes  it  is  filled  with  dreams  and  is  broken  and  fitful.  The 
hallucinations  and  unsystematized  delusions  are  constantly  changing.  There 
is  usually  great  sexual  excitement,  as  shown  by  satyriasis  or  nymphomania. 
There  is  often  a  marked  blunting  of  sensation,  so  that  the  maniac  does  not  feel 
the  wounds  he  inflicts  upon  himself  in  his  blind  fury.  A  remarkable  feature 
is  the  tirelessness  :  it  seems  as  though  no  continuance  of  effort  could  produce 
exhaustion.  The  appetite  is  usually  excellent,  the  digestion  remarkably 
})Owcrful,  the  general  muscular  tone  is  increased,  co-ordination  and  quickness 
of  movement  are  remarkable.  In  spite,  however,  of  the  apparent  perfection 
of  health,  and  in  spite  of  the  taking  of  enormous  quantities  of  food,  the  bodily 
weight  almost  invariably  falls  progressively. 

In  most  cases  of  acute  mania  periods  of  excitement  alternate  with  periods 
of  comparative  calm.  The  usual  duration  of  the  disease  is  from  three  to  six 
months,  although  recovery  may  occur  in  a  few  days  or  be  postponed  for  over 
a  year.  Death  may  take  place  from  exhaustion,  or  the  mental  aberration  may 
pass  into  chronic  mania  or  into  a  condition  of  slight  mental  impairment. 
Complete  recovery  takes  place  in  about  70  ])er  cent,  of  the  patients. 

In  very  many  cases  of  acute  mania  the  symptoms  are  milder,  but  of  simi- 
lar character  to  those  just  detailed.  Restless,  licentious,  blasphemous,  incohe- 
rent, obscene,  the  maniac  lacks  the  fury  of  the  previous  picture,  or,  occupied 
by  his  own  hallucinations  and  delusions,  he  may  be  rapt  in  a  delirium  of 
eniovment.  In  a  still  milder  form  acute  mania  shows  itself  in  incoherence, 
irrationality,  restlessness,  evidences  of  hallucinations  and  delusions,  with 
marked  insomnia,  and  total  loss  of  modesty  and  of  care  for  or  notice  of 
the  usual   relations  of  life.^ 

'The  so-called  "  <r(u/.s(Vo;-?/ //-enz?/ "  is  defined  by  Spitzka  as  "a  condition  of  impaired  con- 
sciousness characterized  by  either  an  intense  maniacal  frenzy  or  a  confused  hallucinatory  delir- 
ium, whose  duration  does  not  exceed  the  period  of  a  day  or  two.  In  its  symptoms  it  resembles 
a  very  violent  acute  mania,  exceiitinp:  in  that  its  duration  is  but  a  few  hours,  and  that  afterward 
the  patient  has  no  remembrance  of  what  took  place  during  the  attack.  It  .scarcely  differs  symp- 
tomatically  from  the  maniacal  fury  which  sometimes  replaces  the  epileptic  convulsion,  except- 
ing in  that  it  docs  not  recMir.  It  is  well  known  that  an  epileptiform  convulsion  may  occur  only 
once,  and  yet  exactly  resemble  the  convulsion  due  to  idiopathic  epilep.sy.  The  relation  between 
transitory  mania  and  epileptic  mania  .seems,  in  ftict,  to  be  the  .same  as  that  which  exists  between 
an  isolated  epileptiform  convulsion  and  a  convulsion  which  forms  one  of  a  true  epileptic  series." 

The  importance  of  this  subject  lies  ciiiefly  in  its  medico-legal  relations.  Thus,  in  a  case 
reported  by  Dr.  Theo.  DilU-r  (Alien iM.  ami  Neurolor/ixt,  1892)  the  patient  killed  his  own  mother 
whilst  in  a  paroxysm  of  transitory  fury  which  developed  during  convalescence  from  influenza. 


MA.XIA.  569 

In  the  mildest  possible  form  of  this  disease — hypomania — the  hallucinations 
may  be  wanting,  and  the  mania  reveal  itself  only  in  a  change  of  character,  a 
peculiar  egotistic  hilarity,  perpetual  extravagances,  restlessness,  increased  sex- 
ual appetite  with  lessened  control  of  the  will-power,  leading  to  great  sexual 
excesses  and  a  tendency  to  brutal  violence.  The  diagnosis  in  these  cases  is 
often  very  difficult,  and  can  be  made  only  by  noticing  the  complete  alteration 
in  the  life,  disposition,  and  mental,  moral,  and  physical  habits  of  the  individ- 
ual. Indeed,  I  believe  that  precisely  as  does  melancholia  (i.  e.  depressive  emo- 
tional condition)  so  also  does  mania  {i.  e.  exalted  emotional  condition)  grade 
insensibly  by  rare  cases  into  the  normal  condition,  and  that  there  are  states  in 
which  the  will  still  exerts  its  control,  although  the  mental  and  moral  attributes 
are  so  altered  that  the  man  is  not  his  natural  self.  Every  one  has  his  hours 
and  sometimes  days  of  exaltation,  as  well  as  his  hours  and  days  of  depression, 
and  exactly  when  or  how  far  the  mood  triumphs  over  the  individual  who 
shall  say  ? 

Chronic  Mania  may  develop  as  the  result  of  an  acute  mania,  or  mav 
come  gradually  without  a  preceding  stage  of  violence.  It  is  a  condition  of 
general  mental  aberration  characterized  by  the  presence  of  varving  or  non- 
systematized  delusions  and  by  a  condition  of  exalted  emotional  excitement. 
In  most  cases  the  chronic  maniac,  although  more  or  less  disturbed  intellect- 
ually all  the  time,  suffers  from  irregular  exacerbations,  in  which  the  condition 
of  excitement  may  become  extreme  and  the  symptoms  rise  in  severity  until 
they  resemble  those  of  an  original  acute  mania.  During  these  paroxysms, 
and  often  indeed  in  the  intermissions,  there  are  incoherence  of  speech,  lack  of 
power  of  association  of  ideas,  delusions,  often  increased  activity  of  the  per- 
ceptive faculties,  with  hallucinations  and  mental  and  physical  excitement. 
The  symptoms  of  chronic  mania  are  similar  to  those  of  acute  mania,  but  are 
less  severe  in  type.  They  are  also  modified  by  the  progressive  failure  in  the 
intellectual  power  as  the  patient  drifts  toward  dementia.  The  hallucinations 
and  delusions  are  unfixed,  constantly  changing,  are  not  systematized,  usually 
are  conformed  to  the  emotional  excitement  of  the  ])atient,  or,  if  they  should 
take  for  the  moment  a  depressive  or  disagreeable  form,  do  not  affect  the  mood 
of  the  individual.  They  may  be  concerning  any  conceivable  person,  thing,  or 
j)lace,  or  may  take  forms  not  reached  by  the  most  vivid  imagination  in  its 
sane  moments.  The  moral  sense  is  completely  altered  or  abolished  :  those  to 
whom  the  individual  had  previously  been  attached  become  objects  of  hate  ; 
modesty  there  is  none,  tlic  patient  revelling  in  obscene  speech  and  innnodest 
gestures,  and  often  suffering  from  sexual  fury.  I^ike  acute  mania,  chronic 
mania  varies  greatly  in  its  intensity  ;  indeed,  the  mild  form  of  mania  know  ii 
as  hvpomania  is  especially  aj^t  to  pursue  a  slow  course,  (chronic  mania  not 
rarelv  changes  into  chronic  melancholia  :  whether  ])ritnary  or  secondary,  it  is 
of  long  duration.  Occasionally  recovered  from,  it  usually  tenninates  in  from 
two  to  five  years  in  d<'menti:i. 

In  tliiH  case  tlio  relations  f)!'  tlit-  palitnt  to  his  inotlu-r  were  such  tiiat  no  prosecution  wa.s  entered 
lijion,  indeed,  rather  strangely,  no  coroner's  inciiiest  seems  to  have  been  iield. 


570  MENTAL    DISEASES. 


Confusion AL  Insanity. 

Definition. — An  acute  insanity  produced  by  nervous  shock  or  exhausting 
disease,  without  distinct  constant  emotional  depression  or  exakation,  with 
marked  abatement  of  mental  power  (ranging  from  a  mild  mental  confusion  to 
complete  imbecility),  often,  but  not  invariably,  accompanied  by  hallucinations 
and  great  mental  excitement ;  with  loss  of  physical  power,  usually  disturb- 
ances of  temperature ;   the  whole  commonly  ending  in  complete  recovery. 

Synonyms. — Primarv  curable  dementia;  Stuporous  insanity;  Stupiditat; 
Delusional  stupor;  Mania  hallucinatoria  ;  Wahnsinn  ;  Surgical  insanity;  Puer- 
peral mania  ;  Post-febrile  insanity ;  Mania  following  typhoid  and  other  acute 
fevers. 

Etiology. — Almost  all  writers  on  insanity  recognize  that  a  violent  sudden 
emotional  strain  may  produce  great  mental  disturbance,  and  even  complete  loss 
of  mental  power.  I  have  seen  the  chagrin  and  worry  of  having  cashed  a  large 
forged  check  produce  in  a  bank-cashier  a  typical  confusional  insanity.  Various 
acute  diseases  are  occasionally  followed  by  insanity.  The  reasons  for  believing 
that  these  insanities  following  acute  disease  are  of  similar  character  are,  first: 
Though  the  cases  vary  very  much  in  their  details,  the  general  scope  of  the  symp- 
toms and  the  general  course  of  the  disorder  are  identical.  There  is  always 
mental  confusion,  a  mixture  of  excitement  and  failure  of  mental  power ;  and 
the  cases  nearly  always  end  in  complete  recovery  if  free  from  organic  disease. 
Second  :  The  belief  that  the  insanity  has  a  specific  relation  to  the  disease  or  to 
the  surgical  operation  which  it  has  followed  necessitates  the  acknowledgment  of 
a  dozen  or  more  acute  insanities  connected  with  specific  diseases.  Thus,  I  have 
seen  the  insanity  after  ovariotomy,  perineorrhapliy,  removal  of  the  breast  for 
cancer,  and  various  other  surgical  operations ;  also  after  rheumatism,  typhoid 
fever,  diphtheria,  epidemic  influenza,  and  various  other  acute  diseases.  All 
these  affections  have  one  influence  in  common — i.e.  they  all  tend  to  exhaust 
<)r  impair  the  nutrition  of  the  nerve-centres;  and  it  is  known  that  impairment 
of  the  nutrition  of  the  centres  by  lack  of  food,  combined  with  anxiety,  is 
capable  of  causing  symptoms  similar  to  those  which  are  present  in  insan- 
ities developed  after  disease. 

Symptomatology.— In  various  chronic  diseases  attended  with  great  bodily 
and  mental  exhaustion  the  brain-tissue  gradually  passes  into  a  condition  of  per- 
verted and  exhausted  nutrition  similar  to  that  of  confusional  insanity.  Prob- 
ably most  of  us  have  seen  in  long-drawn-out  cases  of  consumj)tion  such  a 
gradual  impairment  of  the  mental  faculties,  associated  with  a  superactivity 
of  the  imagination,  as  to  render  the  unfortunate  individual  a  distress  to  himself 
and  to  his  friends.  As  the  disease  progresses  the  mental  disorder  goes  farther, 
and  especially  during  the  night  the  patient  becomes  delirious. 

Almost  every  history  of  shipwreck,  followed  by  long  exposure  and  starva- 
tion, affords  a  recital  of  failing  mental  power,  accompanied  by  increasing 
activity  of  the  imagination,  until  desire  and  thought-pictures  give  rise  to 
hallucinations  which  are  at  first  recognized  by  the  sufferer  to  be  false,  but  at 


CONFUSION  A  L    INSANITY.  571 

last  become  to  him  living  realities,  luring  him  to  leap  overboard  into  what 
seems  to  him  a  land  of  plenty,  but  is  in  truth  a  watery  abyss  of  death. 

In  times  of  famine  or  amongst  the  very  poor  of  certain  parts  of  Eurojie 
habitual  privation  occasionally  produces  a  series  of  symptoms  in  which  the 
delirium  is  subordinate  to  the  complete  mental  failure,  and  that  form  of  con- 
fusional  insanity  known  as  primary  curable  dementia  results  {SUipiditdt — 
Kraft-Ebing) — a  condition  which,  it  must  be  remembered,  may  also  be  caused 
by  sudden  shock,  and  which  grades  through  a  series  of  cases  into  the  second 
variety  of  confusional  insanity. 

In  extreme  cases  representing  the  so-called  primary  curable  dementia  there 
is  almost  complete  paralysis  of  the  mental  function,  with  a  loss  of  nerve-tone  in 
every  portion  of  the  body,  so  that  the  patient  continues  in  a  condition  of  more 
or  less  profound  stupor  or  stupidity,  with  shifting  kaleidoscopic  anomalies  of 
motor  and  vaso-motor  innervation,  and  perhaps  at  times  of  delirium  or  of 
hallucinations.  The  muscular  strength  is  markedly  reduced ;  the  pulse  feeble 
and  small,  usually  quick,  and  greatly  increased  by  voluntary  effort  or  even  by 
active  passive  movements ;  oedematous  swellings  are  frequent,  and  shift  from 
part  to  part  with  remarkable  inconstancy,  but  when,  as  in  many  cases,  the 
patient  for  hours  at  a  time  holds  the  position  of  standing  or  sitting  in  which 
he  has  been  placed,  the  oedematous  swelling  of  the  lower  |)ortions  of  the  bodv 
shows  the  excessive  vaso-motor  weakness.  The  pupils  are  usually  somewhat 
dilated  and  react  feebly  and  slowly.  The  cutaneous  reflexes  are  lessened,  the 
sensibilities  diminished  or  perhaps  almost  altogether  lost.  The  tremors  of 
excef5sive  weakness  are  sometimes  present,  and  there  is  a  condition  of  partial 
catalepsy.  The  bodily  temperature  is  usually  subnormal,  and  in  spite  of  the 
most  careful  and  even  forced  feeding  the  bodily  weight  sinks.  An  almost 
constant  phenomenon  is  an  enormous  increase  of  the  phosphates  in  the  urine. 

In  the  worst  cases,  without  thought  and  without  perception,  speechless  and 
motionless,  reacting  scarcely  at  all  to  any  external  stimuli,  with  even  the  vege- 
tative life  reduced  to  the  lowest  ebb,  the  unfortunate  victim  of  the  disease  still 
cjontinues  the  automatic  life. 

In  the  second  form  of  confusional  insanity  {hallucinatory  insanity)  the  mental 
symptoms  may  seem  to  be  contradictory,  since  many  of  them  are  those  which  are 
commonly  believed  to  be  the  outcome  of  paralysis  of  cerebral  functions,  and 
others  are  such  as  are  sometimes  thought  to  be  evidence  of  excited,  though  per- 
verted, cerebral  activity.  In  the  first  group  belongs  that  depression  of  conscious- 
ness which  in  the  mildest  forms  may  be  shown  only  by  a  peculiar  cjuietude  and 
by  apathy,  but  which  in  varying  degrees  of  greater  severity  manifests  itself  by  a 
stiij)or  which  ever  grows  as  the  disease  becomes  more  severe  in  intensity,  until  it 
deej)ens  into  a  complete,  persistent  loss  of  consciousness.  Another  outcome  of 
cerebral  weakness  is  the  pecidiar  mental  confusion  which  is  the  most  character- 
istic manifestation  of  the  disease.  It  may  reveal  itscJC  chiefly  in  the  inability  of 
the  patient  to  talk  coherently  and  persistently — words  dropping  out  of  the  sen- 
tence or  being  uttered  imperfectly,  because  the  mind  is  unable  to  get  the  right 
word  ;   ideas  clian'jing  in  the  middle  of  a  sentence,  because  IIk^  power  of  confin- 


572  MENTAL    DISEASES. 

ing  the  attention  to  one  consecutive  line  of  thought  is  lost — so  that  the  attempt 
at  conversation  on  the  part  of  the  patient  results  in  a  jumble  of  half  sentences, 
clauses,  and  words  hopelessly  intermixed  one  with  another.  Even,  however, 
in  mild  cases  of  disease  the  mental  confusion  usually  manifests  itself,  not 
merely  in  the  inability  of  the  patient  to  hold  a  connected  conversation,  but  in 
his  want  of  power  to  appreciate  persons  and  things  about  him.  In  the  more 
extreme  instances  no  objects  or  faces  are  recognized,  and  even  in  the  very  mild 
forms  of  the  disorder  the  patient  may  recognize  some  of  his  friends,  yet  be 
unable  to  place  himself,  insisting  that  he  is  away  from  home,  and  pathetically 
begging  to  be  taken  to  his  own  house.  Clinical  experience  has  shown  that 
during  the  acute  stage  of  a  fever  an  inability  to  recognize  familiar  objects,  and 
a  confused,  re})eated  request  to  be  taken  home,  are  of  the  most  serious  prog- 
nostic import :  it  is,  however,  in  the  disease  now  under  discussion  of  no  such 
moment. 

The  confusion  of  the  patient  is  not  altogether  the  outcome  of  pure  mental 
weakness,  but  is  usually  in  part  due  to  the  extraordinarily  numerous  and  vivid 
hallucinations  which  affect  all  the  senses,  and  compete  for  recognition  by  the 
consciousness  with  impulses  which  really  originate  in  external  objects.  The 
weakened  judgment  is  unable  to  distinguish  between  the  contending  claims  of 
subjective  and  objective  sensations,  so  that  realities  and  imaginations  are  inter- 
mingled in  a  hopeless  chaos ;  moreover,  the  memory  is  pronouncedly  affected 
and  old  forms  and  familiar  sights  are  forgotten,  and  the  connection  of  external 
objects  with  the  past  is,  for  the  time  being,  severed. 

A  peculiar  delusion,  that  I  have  so  repeatedly  seen  in  these  cases  as  to 
think  it  is  somewhat  characteristic,  is  that  another  person  or  persons  are  in 
bed  with  the  patient. 

The  delirium  is  commonly  mild  and  lacking  in  aggressiveness,  but  it  may 
take  on  a  very  active  form,  or  the  patient  may  be  habitually  quiet,  but  subject 
to  paroxysms  of  fury  resembling  those  of  acute  mania.  In  these  outbreaks 
the  patient  may  be  violently  erotic ;  indeed,  any  form  of  mania  may  be  coun- 
terfeited. JNIore  commonly,  however,  underlying  even  the  aggressiveness  and 
violence  there  is  a  foundati(m  of  fear  which  often  resembles  that  of  delirium 
tremens,  and  when  with  this  condition  of  fear  there  is  associated  distinct  trem- 
ulousness,  the  likeness  to  delirium  tremens  is  very  pronounced  ;  indeed,  I 
believe  that  delirium  tremens  should  be  considered  a  form  or  variety  of  con- 
fusional  insanity. 

The  physical  condition  and  symptoms  in  this  form  of  confusional  insanity 
are  similar  in  nature  to,  but  usiially  less  pronounced  than,  those  of  so-called 
primary  dementia.  liittle  attention  has  been  paid  by  writers  to  the  bodily 
temperature,  and  unfortunately  I  have  seen  the  disease  almost  exclusively  in 
consultation,  under  circumstances  which  too  often  have  rendered  temperature- 
sheets  unattainable.  It  is  certain,  however,  that  the  temperature  varies  in  dif- 
ferent cases.  It  may  be  normal,  but  in  severe  cases  there  is  usually  either  an 
habitually  low  tem]>erature  or  a  marked  tendency  to  paroxysms  of  subnormal 
temperature.    On  the  other  hand,  there  may  be  a  very  distinct  febrile  reaction. 


VOXFl  'SIOX.  1  /.    IXS.  ( XI T  }  '. 


573 


This  I  li:ivo  espet-ially  seen  in  puerperal  eases.  When  fever  exists  at  all,  the 
swiiio;  of  the  thermonietrical  mercurv  is  remarkable  for  its  irreorularitv  and  its 
extent,  and  a  very  iiigii  temj)erature  is  often  followed  by  a  sudden  and  marked 
fall  below  the  norm.  In  order  to  show  the  peculiarities  of  temperature  the 
followinii;  reproduction  of  the  chart  of  a  case  of  the  puerperal  form  of  the  disease 
is  appended  : 

Fi?.  44. 


>•       i>       2j        24       >S        <6       27       38        37      30       31        I         '3456         7  8         9        10       U        12       IJ        14 

The  figures  at  the  bottom  represent  the  days  of  the  month,  beginning  June  I'lst. 

Diagnosis.— Very  rarely  ought  there  to  be  any  trouble  in  recognizing 
the  true  nature  of  confusional  insanity.  The  history  of  the  attack,  the  know- 
ledge that  the  outbreak  has  been  preceded  by  an  exhausting  disease,  trauma- 
tism, or  emotion,  the  failure  of  bodily  nutrition  and  of  general  nerve-force, 
the  lack  of  dominant  emotional  excitement,  the  stupor,  the  peculiar  mental 
confusion,  the  kaleidoscopic  character  of  the  hallucinations, — all  these  make 
dia^-nosis  easv. 

Prognosis. — The  prognosis  in  confusional  insanity  is  favorable.  Kraift- 
Ebing  states  that  70  per  cent,  of  his  cases  have  recovered,  and  in  my  own 
experience,  even  when  the  mental  confusion  has  amounted  to  complete  and 
absolute  imbecility,  complete  recovery  has  almost  invariably  occurred,  pro- 
vided that  there  have  been  no  pre-existing  organic  bodily  lesions,  such  as  un- 
sound kidneys  or  degenerated  arteries.  Death  may,  however,  occur  in  com- 
jilicated  cases.  If  the  mental  recovery  be  not  complete,  the  result  is  lack  of 
mental  power,  but  never  a  reasoning  insanity,  never  a  state  resembling  that  of 
paranoia. 

It  must  be  remembered,  however,  that  an  emotional  shock  may  produce  an 
absolute,  permanent  overthrow  of  the  intellectual  faculties.  Thus,  Bucknill 
and  Tukc  record  a  case  in  which  a  young  lady  of  refinement  and  education 
was  assaultwl  and  raped  by  a  band  of  ruffians,  and  became  at  once  a  speechless 
idiot  for  life.  In  a  second  case  a  young  lady,  having  by  mistake  fatally 
poisoned  her  father,  from  the  time  of  his  death  "  was  lost  to  all  knowledge  or 
notice  of  ])ei'sons  and  occurrences  around  :  food  she  never  took  except  wIkmi  it 
was  placed  upon  her  tongue;  the  only  sound  which  escaped  her  lips  was  a  faint 
yes  or  no." 

Treatment. — Usually  the  first  question  to  be  settled  in  the  treatment  of 
confusional  insanity  is  as  to  whether  th<!  patient  shall  be  sent  to  an  asylum  or 
kept  at  home.  The  proper  answer  to  this  depends  absolutely  upon  the  pecuni- 
ary circumstances  of  the  sick  person.  If  there  be  abundant  means  to  provide 
a  sufficiency  of  trained  nurses,  it  is  nuich  better  to  keep  the  patient  in  his  own 


574  MENTAL    DISEASES. 

house.  Nothing  can  be  done  in  an  asyhim  that  cannot  be  as  well  done  at  home, 
and  as  the  person  returns  to  mental  health  the  shock  and  depression  of  finding 
himself  within  the  walls  of  an  insane  asylum  may  greatly  retard  or  prevent 
convalescence.  If,  however,  the  pecuniary  means  be  restricted,  it  is  essential, 
in  severe  cases,  to  emjiloy  asylum  treatment.  Unless  there  can  be  an  abundance 
of  thoroughly  trained  nurses  there  is  little  chance  that  the  patient  will  be  prop- 
erly fed  and  cared  for,  and  the  feeding  is  of  the  greatest  importance.  The 
appetite  is  usually  nil,  but  the  powers  of  digestion  are  commoidy  much  better 
than  they  seem,  so  that  forced  feeding  is  well  borne.  Again,  not  rarely  the 
patient  refuses  food  either  in  })art  or  altogether,  and  then  artificial  feeding  must 
be  resorted  to,  which,  of  course,  requires  skilled  attendants.  In  all  cases  the 
administering  of  nutritious  and  even  rich  food  at  short  intervals,  in  as  large 
quantities  as  the  stomach  will  tolerate,  should  form  the  basis  of  treatment.  In 
a  most  severe  case  a  patient  of  my  own  took  daily  for  weeks  sixteen  raw  eggs 
in  six  pints  of  milk,  with  most  happy  results.  Usually  it  is  necessary  to  give 
the  food  in  liquid  form. 

A  ])oint  to  which  I  think  sufficient  attention  is  not  given  is  the  maintenance 
of  the  bodily  warmth  of  the  patient :  by  overheated  rooms,  by  hot-vyater  beds 
or  bags  of  hot  water,  and  by  the  warmest  clothing  obtainable  every  effort  should 
be  made  when  the  temperature  is  subnormal  to  restore  it.  An  alarming,  if  not 
fatal,  fall  of  temperature  is  liable  to  occur  suddenly  and  unaccountably,  and  to 
be  overlooked  till  the  patient  passes  into  a  collapse  which  may  be  hopeless. 
The  nurses  ought,  therefore,  to  be  instructed  to  continually  watch  the  tem- 
perature of  the  patient,  and  in  the  absence  of  a  physician  to  institute  the 
])ro])er  means  for  heating  the  body  whenever  the  bodily  heat  falls  below 
97°  F. 

Rest,  massage,  and  exercise  are  three  hygienic  measures  which  must  be  care- 
fully apj)Iied  in  every  case.  Their  use  is,  of  course,  directed  against  the  physical 
side  of  the  disorder,  and  they  are  to  be  employed  precisely  as  they  would  be  in 
similar  bodily  conditions  without  distinct  disturbance  of  the  mental  functions. 
It  must  be  remembered  that  the  underlying  bodily  condition  is  one  of  exhaus- 
tion, so  that  rest  rather  than  exercise  is  needed.  In  bad  cases  the  rest  must  at 
first  be  absolute,  and  it  sometimes  happens  that  the  exhaustion  is  too  extreme 
even  for  the  use  of  massage.  Later  in  the  treatment  massage  and  electrical 
stimulants  are  often  of  very  great  service.  It  sometimes  happens,  especially 
in  severe  cases,  that  after  a  time  the  bodily  strength  increases  without  a  cor- 
responding growth  in  mental  power :  under  such  circumstances  I  have  found 
a  removal  from  the  home  surroundings  to  the  seashore,  mountains,  or  other 
places  of  resort,  combined  with  the  encouragement  of  out-door  exercise  of  a 
not  too  severe  type,  to  be  followed  by  the  happiest  results. 

Drugs  are  to  be  employed  with  a  twofold  object :  First,  and  chiefly,  to 
increase  the  nutrition  of  the  nerve-(!entres  and  general  tissues  of  the  body  : 
for  this  ]>urpose  iron  combined  with  bitter  tonics,  administered  in  small  or 
large  quantities  according  to  the  individual  character  of  the  case,  strychnine 
given   in  ascending  doses  to  the  limit  of  physical  tolerance,  and  phosphorus 


TERMINAL    DEMENTI  A.— NEUROPATHIC  INSANITY.      575 

continuously  e.xliihited  in  such  small  doses  (yl^  to  y^  of  a  grain)  as  not  to 
disturb  digestion,  I  have  found  to  be  of  great  service.  Second,  to  obtain  sleep 
when  there  is  wakefulness  or  to  quiet  delirious  excitement.  Here  the  bromides 
naturally  suggest  themselves,  and  they  are  often  used  in  very  large  quantities: 
it  should  be  remembered,  however,  that  the  bromides  are  powerful  depressants, 
not  merely  to  the  functional,  but  also  to  the  nutritive,  activity  of  the  nerve- 
cells  ;  and  I  am  sure  that  I  have  seen  very  distinct  injury  done  by  their  free 
use  in  confusional  insanity.  In  an  individual  case  the  selection  of  a  hypnotic 
or  quietant  is  to  be  based  chiefly  upon  the  results  of  trial.  In  some  instances 
opium  seems  to  act  favorably  ;  more  commonly  hyoscine  is  of  advantage. 
Chloral  and  sulphonal  ought  certainly  to  be  tried  on  occasion.  As  a  calmative 
the  hot-pack  is  often  very  serviceable,  and  I  have  seen  a  very  active  deliriimi 
apparently  greatly  benefited  by  free  blistering  of  the  scalp. 

Terminal  Dementia. 
Almost  any  form  of  active  insanity  may  be  followed  by  a  long-continued 
condition  in  which  the  mind  is  so  far  lost  that  even  the  distinctive  character- 
istics of  the  original  insanity  have  more  or  less  completely  disa})peared.  Tiiis 
state  is  the  so-called  secondary  or  terminal  dementia.  The  completeness  of 
the  mental  ruin  varies:  in  some  cases,  apathetic,  mindless,  without  thought  or 
emotion,  the  individual  lives  on,  a  mute,  almost  motionless,  vegetating  autom- 
aton ;  in  other  instances,  restless,  full  of  obtrusive  or  destructive  activity, 
noisy,  with  incoherent  talk,  the  dement,  although  overflowing  with  animal 
spirits,  and  perhaps  also  possessed  by  a  peculiar  aggressive  egotism,  is  useless 
for  any  purpose — mayhap  is  almost  uncontrollable  and  very  troublesome. 
Sometimes  the  mental  condition  is  simply  that  of  a  weak-mindedness,  and  the 
harmless  imbecile  seems  like  an  overgrown  child.  No  medical,  hygienic,  or 
moral  treatment  can  in  these  cases  avail  anything  to  restore  the  lost  mental 
power,  and  the  only  thing  to  do  is  to  take  care  of  the  individual.  Not  rarely 
a  little  intellectual  power  remains  ;  and  if  with  this  there  be  docility,  the 
dement  may  be  usefully  employed  about  a  farm,  in  the  wards  of  a  hospital,  or 
in  other  situations  in  which  he  can  be  carelully  watched  over  and  constantly 
directed  and  taken  care  of. 

Neuropathic  Insanity. 

Etymologically,  the  term  "  neuropathy  "  means  disease  of  the  nervous  .sys- 
tem. Bv  modern  neurologists,  however,  the  term  is  commonly  us(>d  in  a 
more  rei^tricted  sen.se,  and  especially  as  the  basis  of  the  adjective  "neuro- 
pathic," to  designate  the  condition  in  which  abnormal  symptoms  are  produced 
by  an  original  and  ac(piired  vicious  development  or  failure  of  doveloi)nient  of 
the  nervous  centres. 

Insanities,  nervous  disea.ses,  drunkenni'ss,  .syi)hilis,  aleoliolism,  excessive 
poverty  and  lack  of  the  necessities  of  life, — these  and  other  similar  active 
causes  in  the  parent  lead  to  degradation  in  the  oflspring;  whilst  onanism, 
taught  perhaps  even  in  infancy  ;  the  overcrowding,  the  imder-feeding,  :uid  the 


576  MENTAL    DISEASES. 

miiltitiulinous  ills  which  come  to  the  young  life  born  in  the  midst  of  extreme 
jioverty  ;  various  injuries  in  early  life  ;  acute  and  chronic  diseases  setting  in 
before  the  nervous  system  has  unfolded  itself, — these  and  a  thousand  other 
similar  possible  ills  frequently  cause  in  the  unfortunate  children  of  the  human 
race  a  nervous  system  which  for  ever  dooms  its  victim  to  an  unhappy  pecu- 
liarity amongst  his  fellows.  Once  engendered,  the  neuropathic  constitution 
magnifies  itself  through  generations,  and  so  root-stocks  appear  from  wdiich 
spring  criminals,  lunatics,  and  a  midtitude  of  other  beings  concerning  whom 
the  world  wonders  whether  they  should  be  considered  sane  or  insane.  In 
very  truth,  there  is  no  line,  at  least  none  that  can  be  drawn  by  the  finite 
mind.  The  offspring  of  such  parentage  may  perform  all  the  duties  of  life, 
but  his  mental  organization  lacks  something  or  has  suffered  some  twist. 

Perverse,  drifting  almost  of  necessity  into  criminal  acts,  eccentric,  such  unfor- 
tunates are  a  long  series  of  human  atoms  whose  faulty  brain-organization  sepa- 
rates them  from  their  more  fortunate  fellows.  When  this  separation  is  sufficiently 
wide,  when  the  mental  organization  is  so  bad  that  every  one  can  perceive  that 
the  man  is  the  victim  of  his  own  imperfectly-developed  brain,  he  is  said  to  be 
insane.  But  when  the  unfortunate  individual  is  a  little  more  like  the  normal 
human  being,  he  is  looked  upon  simply  as  eccentric,  perverse,  or  wicked,  and, 
unloved  and  unpitied,  drifts  through  life,  sometimes  to  poverty,  sometimes  to 
the  hospital,  sometimes  to  the  jail,  and,  it  may  be,  to  the  hangman's  scaffold. 
Sanity,  insanity,  criminality,  power  over  self,  free  will,  mental  attributes, — 
these  and  similar  terms  are  household  words  with  all  of  us,  but  no  man  knows 
whence  they  come  or  what  they  are,  or  how  far  the  individual  is  master  of 
himself  or  is  driven  by  the  hand  of  fate  as  represented  in  the  physical  con- 
formation of  the  nerve-cells  and  fibres  of  his  brain. 

As  has  already  been  insisted  upon,  insanity  is  not  a  disease  or  a  distinct 
entity.  Necessity  for  an  arbitrary  line  between  sanity  and  insanity  is  not  of 
scientific  but  of  legal  origin,  and  when  the  medical  expert  affirms  that  he  is 
unable  to  measure  out  accurately  the  exact  degree  of  human  responsibility,  he 
simply  acknowledges  that  he  himself  is  a  finite  being  and  that  the  problems  of 
life  baffle  his  utmost  thought.  It  has  been  reserved  forjudges  upon  the  bench 
and  lawyers  at  the  bar  to  arrogate  to  themselves  the  attribute  of  infinity  ; 
whilst  ministers  of  the  gosi)el  but  too  often  teach  that  the  last  and  highest 
revelation  of  a  merciful  God  is  that  this  poor,  broken  humanity,  helpless  so 
often  in  the  iron  grip  of  its  own  perverse  nature,  shall  be  punished  by  flames 
eternal. 

In  obedience  to  some  mysterious  law  of  nature  the  neuropathic  victim  may 
be  possessed  of  very  high  intellectual  power,  there  being,  indeed,  a  close  rela- 
tion between  mental  aberration  and  that  power  of  original  creative  thought  to 
which  we  give  the  name  of  genius.  This  has  been  denied  by  no  less  a  physi- 
ologist than  Claude  Bernard,  who  lays  stress  upon  the  fact  that  genius  is  not 
heritable,  whilst  madness  is.  This  is,  however,  no  proof  of  the  absence  of 
relations  between  the  two.  Genius  is  not  madness,  but  simply  a  possible  off- 
shoot from  a  stock  of  mad  ancestry.     Genius  may  exist,  as  in  Goethe,  com- 


NEUROPATHIC  jySAXITY.  577 

bined  with  the  hiuliest  of  reasoning  pt)\v(>rs,  hut  jx'rhnps  nioro  iisuallv  it  is 
associated  with  mental  and  physical  qualities  which  are  but  too  plainlv  the 
outcome  of  defective  or  peculiar  mental  organization. 

It  cannot  be  a  mere  accident  that  so  large  a  proportion  of  those  whom  the 
world  speaks  of  as  "children  of  genius"  liave  had  an  intellectual  life  spent 
upon  the  border-land  of  insanity,  or  a  moral  history  setting  them  apart  from 
the  normal  human  being  and  showing  but  too  clearly  the  traces  of  their  ances- 
try. Space  is  wanting  to  do  more  than  call  attention  to  the  monomania  of 
John  Bunyan,  whose  immortal  dream  was  no  doubt  to  himself  often  more 
than  a  dream  ;  to  the  overweeiu'ng  egotism  of  Bvron  ;  to  the  asronics  of  mental 
depression  which  overshadowed  the  life  of  Cowper ;  to  the  hereditary  madness 
which  led  to  orgies  of  insane  cruelty  in  so  many  of  the  world's  ablest  despots, 
whether  among  the  more  ancient  Romans  or  in  the  more  recent  Russian  dvnas- 
ties  of  Rurik  and  of  the  Romanoffs  ;  to  the  hallucinations  which  caused  Swe- 
denborg  to  affirm  that  the  hand  of  Christ  "squeezed  my  hand  hard,"  and 
Luther  to  declare  that  the  devil  came  into  his  cell,  stamped  through  his 
cloister,  and  drove  him  from  his  bed  ;  to  the  glorious  visions  which  inspired 
Joan  d'Arc  with  a  faith  almost  divine  and  an  energy  irresistible:  to  the 
direct  communications  with  God  which  enabled  the  son  of  Abdallah  to  link 
together  millions  in  a  confederacy  of  religious  belief  against  which  Chris- 
tianity has  beaten  as  yet  in  vain.  Edgar  Poe,  Heine,  Munger,  Baudelaire, 
Gerard  de  Nerval,  Maupassant,  Swift,  Pascal, — these  and  many  other  examples 
might  be  cited  as  showing  how  close  genius  is  to  the  mind  diseased  ;  but  need  of 
brevity  forbids.  I  cannot,  however,  forbear  mentioning  at  somewhat  greater 
length  the  immortal  Victor  Hugo,  whose  uncle  died  insane,  whose  brother 
Charles  (perhaps  more  talented  than  himself)  entered  for  life  the  madhouse 
before  twenty  years  of  age,  Mdiose  daughter  is  insane,  and  of  whom  the  Lon- 
don Medical  Times  is  not  far  wrong  in  affirming  that  some  of  his  finest  pro- 
ductions are  those  indelil)]y  stamped  with  madness.  A  remarkable  fact  in  the 
mental  history  of  this  greatest  of  poets  was  that  along  with  his  extraordinary 
imagination  there  was  a  shrewdness  almost  as  great.  No  banker  could  have 
more  carefullv  managed  his  fortune — no  ])oHtician  could  have  more  tenderly 
nursed  his  popularity.  He  who  had  amassed  over  a  million  of  dollars  died 
the  idol  of  a  communistic  democracy — he  who  had  ])laved  at  fast  and  loose 
with  all  political  parties  was  buried  amidst  a  tmnult  of  universal  sorrow. 

Already  in  the  mildest  forms  of  neuropatiiic  brain-weakness  the  cases 
arrange  themselves  into  two  groups.  Li  the  one  tiie  disordered  enervation 
shows  itself  especially  in  the  realm  of  intellectual  action  ;  in  the  other  the 
morbid  or  ill-dcv(^loped  nervous  system  betrays  itself  in  the  sphere  of  morals. 
In  (he  first  group  belong  chiefly  those  \\{ho  are  known  in  the  community  as 
"  harmless  cranks,"  whilst  the  sec(jnd  group  is  made  u|)  chiefly  of  the  so-called 
"criminal  classes."  Of  course  in  the  actii;il  life  cNcry  grade  exists  between 
ihe  man  whose  eccentricities  show  (heinselves  jtei'liaps  in  (he  extreme  piety 
as  well  as  in  (he  disoideivw]  ii)(ellection,  and  (he  ninii  whose  eccenlricity  is  in 
the  sphere  of  nioial  ehar;ic(er. 
Vol..  I.— 37 


578  MENTAL    DISEASES. 

In  common  witla  most  alienists  I  believe  that  there  are  neuropathic  subjects 
who  should  be  considered  to  have  passed  over  the  boundary-line  of  insanity, 
although  they  have  no  actual  delusions.  I  am  fully  persuaded  that  some  of 
these  subjects  are  actually  unaccountable  beings,  who  are  the  sport  of  their 
own  morbid  nervous  organizations.  Pi'obabiv  in  all  such  cases  both  the 
moral  and  the  intellectual  character  is  affected,  but  in  some  subjects  the  per- 
turbation is  most  obvious  in  the  moral;  in  others  in  the  intellectual,  sphere ; 
consequently,  these  cases  of  insanity  are  divided  by  some  of  the  best  alienists 
into  reasoning  insanity  [folie  ralsonnante)  and  moral  insanity. 

Sometimes  in  reasoning  insanity  emotioiuxl  exaltation  exists,  when  the  cases 
are  spoken  of  as  being  maniacal ;  in  other  subjects  the  depressing  emotions 
are  dominant  and  the  individual  is  melancholic.  Reasoning  insanity  includes 
those  cases  in  which,  perhaps  along  with  high  intellectual  endowments,  there 
exist  imperative  conceptions  or  morbid  impulses  of  such  power  as  to  dominate 
the  life  of  the  patient.     (See  page  539.) 

As  has  already  been  shown,  the  morbid  impulse  is  very  closely  related  to, 
indeed,  often  springs  from,  the  imperative  conception,  whilst  the  imperative 
conception  has  the  closest  of  relations  Avith  delusions.  The  sequence  of  cases 
in  nature  from  eccentricity  to  reasoning  insanity  without  delusions,  and  from 
reasoning  insanity  M'ithout  delusions  to  paranoia  with  delusions,  is  unbroken. 
A  very  curious  form  of  reasoning  insanity  is  folie  du  donte,  or  doubting  insan- 
ity, in  which  the  patient  is  entirely  without  confidence  in  the  integrity  and 
reliability  of  his  own  mental  processes.  This  mental  condition  may  be  looked 
upon  as  an  exaggeration  of  self-distrust,  and  when  it  is  complete  leads  to 
insanity  of  conduct.  Thus,  a  patient  said  to  me,  "  Two  and  two  make  four ; 
so  my  intellect  tells  me,  but  how  do  I  know  that  my  intellect  is  in  its  conclu- 
sion right?"  "  I  change  my  baby's  diaper  at  night ;  a  moment  later  1  remem- 
ber doing  it,  but  how  do  I  know  that  my  memory  is  correct  or  that  the  feeling 
of  dryness  which  my  hand  gives  me  is  true?"  '  And  so  the  unfortunate  woman 
and  the  almost  equally  unfortunate  baby  spend  hours  in  the  ])rocesses  of  uncov- 
ering and  being  uncovered. 

Moral  lunatics  are  those  who  are  not  only  devoid  of  all  conscience,  but 
actually  are  driven  by  their  natures  to  what  seem  to  others  horrible  crimes. 
Thus,  in  the  case  reported  in  the  American  Journal  of  Insanity  the  lust  for 
blood  and  the  sight  of  suffering  were  only  satisfied  with  torture  and  murder. 
This  man  was  a  moral  imbecile  driven  by  a  furious  impulse  to  torture  and 
kill :  to  tie  uj)  horses  in  the  woods  and  gradually  whittle  them  to  death,  to 
mutilate  living  cats,  to  torture  chickens,  to  break  the  legs  and  tear  to  pieces, 
whilst  living,  small  birds,  were  his  greatest  pleasure;  but  the  very  heaven  of 
his  joy  was  reached  by  assaulting,  torturing,  killing  human  beings.  When 
twelve  years  old  he  took  his  toddling  brother  into  the  woods  and  nearly 
flogged  him  to  death.  He  attempted  to  strangle  a  younger  brother  and  to 
smother  his  infant  sister;  had  stabbed  various  people,  essayed  to  suffocate 
a  harmless   imbecile,  and  to  choke  another  inmate  of  the  asylum,  and  com- 


PAh'AAO/A.  579 

mitted  at  least  two  criminal  assaults  on  women,  the  last  during  an  escape  from 
the  asylum. 

Lack  of  space,  however,  forbids  further  consideration  here  of  tiiese  strange 
insanities,  and  the  curious  reader  is  referred  to  larger  treatises  on  the  subject. 

Amongst  the  moral  insanities  must  be  classed  the  various  sexual  perver- 
sions. Without  doubt,  vice  may  gradually  lead  a  man  on  to  all  the  besti- 
alities of  sodomy,  but  there  are  certainly  individuals  who  are  born  with  a 
perverted  sexual  sense  which  leads  them  to  enjoy  from  the  earliest  pubertv 
only  the  embraces  of  their  own  sex.  Such  men  often,  but  not  alwavs,  have 
feminine  voices  and  feminine  ways,  mincing  as  they  go,  dressing  in  private  in 
women's  clothes,  affecting  all  the  airs  and  ways  of  the  silly  type  of  woman- 
hood. I  have  examined  in  prison  such  men,  whose  statements  that  thev  did 
not  masturbate  were  confirmed  after  careful  watching  and  long  study  bv  an 
experienced  prison  surgeon.  They  affirmed  that  from  earliest  puberty  women 
had  been  to  them  objects  of  aversion,  and  on  the  rare  occasions  when,  under 
stress  of  circumstances,  intercourse  had  taken  place,  no  pleasurable  orgasm  had 
accompanied  emission  ;  but  of  man  they  spoke  with  raj)ture,  and  their  eyes 
would  glisten  with  lustful  excitement  at  the  mere  sight  of  a  handsome,  well- 
formed   man. 

Prognosis  and  Treatment. — In  all  cases  of  neuropathic  insanity  the 
prognosis  is  very  grave  in  regard  to  the  mental  condition,  but  very  favorable 
in  regard  to  life:  the  insanity  being  founded  upon  original  or  acquired  neur- 
opathy, remission  is  the  most  that  can  be  hoped  for. 

It  is  also  evident  that  there  can  be  no  specific  treatment.  The  object  of 
the  practitioner  is,  by  moral  and  physical  hygiene,  to  give  robustness  to  the 
nervous  system,  and  by  means  of  narcotics,  very  carefully  and  sparingly  used, 
to  subdue  nervous  excitement  when  it  shall  rise  too  high.  In  the  majority  of 
cases  the  victim  of  an  insane  neuropathy  enjoys  life,  on  the  whole,  better 
within  a  well-regulated  asylum  ;  and  in  a  large  proportion  of  cases  it  is  only 
possible  to  protect  society  from  the  lunatic  and  the  lunatic  from  himself  by 
sequestration. 

When,  in  the  neuropathi€  subject,  delusions  appear,  the  case  is  absolutely 
and  undisputably  one  of  insanity,  so  that,  whatever  may  be  our  opinion  in 
regard  to  the  propriety  of  acknowledging  the  fornix,  of  insanity  just  spoken 
of,  all  must  agree  that  paranoia,  or  neuropathic  insanity  with  a  more  or  less 
uniform  mental  state,  and  periodical  insanity,  or  neuroj)athic  insanity  with 
periodical  alterations  of  the  mental  condition,  icpresent  true  insanities. 

Paranoia. 

Definition. — Insanitv  dependent  upon  original  neurotic  vices  accompanied 
by  more  or  less  distinctly  systematized  delusions,  ])ersi.^tent,  and  without  cycli- 
<»1  delusions. 

Etiolog-y. — In  the  great  majority  of  cases  of  paranoia  there  is  a  distinct 
liereditarv  neuropathy,  Imt  in  a  small  inopoi'tion  of  the  ca.scs  the  constitutional 


580  MENTAL    DISEASES. 

neurosis  can  be  traced  to  drunkenness  or  oilier  vice  in  tlie  parents,  or  to  injury 
or  disease  occurring  during  early  childhood. 

Symptomatolog-y. — Paranoia  usually  develops  slowly,  blossoming  out 
of  a  character  which  has,  from  the  very  beginning  of  life,  shown  clearly  the 
tendency  to  neuropathic  madness.  In  rare  cases  the  symptoms  of  insanity  are 
developed  suddenly  in  an  acute  maniacal  or  delirious  attack.  The  delusions 
of  j)aranoia  are  very  frequently,  but  not  always,  accompanied  by  or  even 
dejjendent  upon  hallucinations,  which  are  said  to  be  most  frequent  in  the 
sphere  of  hearing,  next  in  that  of  feeling,  then  in  seeing,  tasting,  and 
smelling. 

The  couree  of  paranoia  is  essentially  chronic,  and  it  is  doubtful  whether 
permanent  positive  cure  can  ever  occur  in  a  disease  which  is  so  intimately 
connected  with  an  original  vice  of  nervous  development.  Nevertheless,  inter- 
missions are  not  rare,  and  may  continue  for  months  or  even  years.  They 
sometimes  seem  to  be  almost  complete,  but  usually  some  evidences  of  mental 
aberration  are  discoverable.  After  a  shorter  or  longer  time  distinct  insanity 
recurs — not,  however,  in  the  form  of  a  new  attack  so  much  as  in  that  of  a  con- 
tinuance of  the  old,  the  new  attack  being,  as  it  were,  knotted  to  the  insane 
life  which  has  gone  before  it.  In  judging  of  any  individual  case  as  to  the 
present  mental  condition  it  must  be  remembered  that  the  paranoiac  not  rarely 
hides  his  delusions  and  simulates  an  intermission. 

Exacerbation  also  occurs  in  paranoia,  accompanied  it  may  be  with  great 
cerebral  excitement,  sleeplessness,  and  very  pronounced  psychical  symptoms, 
such  as  ecstasy,  violent  hallucinatory  delirium,  fierce  mania,  stuporous  demen- 
tia, etc.  Again,  some  other  form  of  insanity  may  develop  during  a  paranoia ; 
thus,  dementia  paralytica  is  probably  more  frequent  in  the  victims  of  a  con- 
firmed neuropathy  than  in  ordinary  life,  whilst  alcoholic,  hysterical,  or 
epileptic   madness   are  comparatively  infrequent. 

Paranoia  very  rarely,  if  ever,  ends  in  complete  dementia,  but  rather  in 
a  condition  of  psychical  weakness  and  good-natured  stupidity,  through 
which  may  be  preserved  a  certain  show  of  the  artistic,  professional,  or 
technical  abilities  originally  possessed  by  the  subject.  Almost  every  large 
asylum  has  in  it  such  patients,  to  whom  the  asylum  has  become  a  beloved 
home,  and  by  whom  much  of  the  work  of  the  institution  is  performed. 

Paranoiacs  may  be  divided  into  those  cases  in  which  the  symptoms  develop 
about  the  period  of  puberty  and  those  in  which  the  active  symptoms  come  on 
later. 

Early  Paranoia. — The  paranoia  of  pubescence,  or  hebephrenia,  usually 
occurs  in  children  whose  mental  life  has  given  evidences  of  abnormality  very 
early  in  life.  According  to  Kraff't-Ebing,  in  Europe  such  children  are  espe- 
cially prone  to  believe  themselves  "  Cinderellas  for  whom  no  fairy  has  awaited ;" 
to  become  dissatisfied  with  their  surroundings;  to  dream  of  higher  positions  in 
society;  to  perceive  in  themselves  unlikeness  to  their  own  family  and  a  like- 
jiess  to  some  family  of  higher  rank  ;  and  as  the  years  go  by  to  persuade  them- 
selves that  they  arc  the  thing  that  they  originally  longed  to  be — namely,  the 


PARAXOTA.  581 

neglected  offspring  of  count  or  prince  or  otlier  social  digiiitarv.  Probably, 
owing  to  the  fact  that  the  difference  between  social  classes  in  America  is 
comparatively  slight,  this  ])eculiar  development  of  paranoia  is  with  us  rare. 
More  common  is  an  obtrusive  self-assertion,  combined  with  a  mawkish 
sentimentality  and  sexual  irregularities.  Xot  rarely,  at  the  time  when  the 
character  of  the  boy  should  develop  into  that  of  the  man,  an  arrest  in  the 
character  seems  to  take  place,  and  the  silly  egotism  of  adolescence  becomes 
the  permament  stamp  of  the  degraded   mentality. 

The  psychosis  frequently  conmienccs  with  depression  of  s))irits,  which  is, 
however,  usually  not  so  absolute  as  in  original  melancholia,  and  is  very  often 
associated  with  an  almost  iiysterical  desire  for  symj)athy,  obtrusiveness 
replacing  the  peculiar  reticence  of  true  melancholia.  A^ery  often  the  mental 
deterioration  is  rapid,  and  it  may  be  so  complete  as  to  siuudate  a  dementia. 
Abnormalities  of  sexual  life  are  almost  universal.  In  the  oreat  maioritv  of 
cases  the  patients  are  inveterate  and  excessive  masturbators,  and  especially  in 
women  life  is  sometimes  given  up  to  a  neurotic  dream  of  love,  which  centres 
about  some  person — usually  of  high  rank — with  whom  the  subject  may  not 
even  have  acquaintance. 

Late  Paranoia. — Late  paranoia  develops  after  the  com])letion  of  puberty, 
and  very  frequently  not  until  the  fortieth  or  fiftieth  year  of  life.  Almost  in- 
variably, however,  the  subject  of  the  disorder  has  been  from  early  life  eccen- 
tric in  thought  and  in  action.  In  a  large  proportion  of  cases  the  disease 
develops  gradually,  the  delusions  forming  in  the  mind  so  slowly  that  it  is 
almost  impossible  to  say  when  their  seeds  have  germinated.  On  the  other 
hand,  in  some  cases  the  first  distinct  mental  aberration  is  a  violent  attack  of 
delirium  which  may  simulate  an  acute  mania.  Again,  a  severe  catarrhal 
attack,  a  sudden  uterine  disorder,  a  j)reguancy,  a  tyjjhoid  or  other  constitu- 
tional fever,  may  be  the  abrupt  starting-point  for  a  paranoia  which  may 
readily  be  mistaken  fi)r  a  coufusional    insanity. 

The  cases  of  paranoia  differ  very  much  in  the  nature  of  their  delusions  and 
in  their  general  symptoms,  but  for  the  purposes  of  discussion  they  may  be 
arranged  in  groups,  it  being  remembered  that  these  groups  merge  into  one  an- 
other, and  that  sometimes  the  character  of  the  individual  case  changes  diu'ing 
its  course. 

The  most  common  form  of  paranijia  is  that  attended  with  delusions  of  per- 
secution. In  the  beginning  the  subject  feels  that  the  world  is  becoming  hostile 
to  him,  or  suspicion  attaches  in  his  mind  to  a  certain  individual  or  individuals 
as  viewing  him  with  distrust:  as  time  goes  by  suspicion  becomes  more  intense  ; 
a  look,  a  whispered  word,  a  momentary  gesture,  a  sermon,  are  in  his  thought 
proof  of  hostile  intent.  The  manner  becomes  unquiet,  whilst  the  face  i)er- 
chancc  puts  on  a  hunted,  anxious  look.  Little  by  little  suspicion  increases  to 
belief,  and  graduallv  or  suddenly,  as  the  case  may  be,  the  paranoiac  /choice  that 
he  is  the  object  of  persecution,  that  attempts  are  being  made  by  poison  or  in 
other  wavs  U])on  his  life,  tli;it  lie  is  aeensed  of  crime  and  thi-eatened  by  the 
police,    etc.        In    its   delusiuns   the    mind    often    responds   to    il>    envii-oniuent. 


682  MKNTAL    DISEASES. 

Thus,  in  Europe  the  paranoiac  frequently  believes  himself  the  object  of 
political  persecution  :  in  America  private  individuals  rather  than  government 
officials  that  oppress  him. 

Very  frequently  the  delusions  have  a  sexual  tinge :  the  world  is  conspiring 
against  the  man's  sexual  life  or  sexual  power,  or  suspicion  is  directed  against 
the  fidelity  of  the  wife  or  on  the  part  of  the  wife  against  the  fidelity  of  the 
husband.  Usually,  about  the  time  when  the  delusions  become  fixed,  halluci- 
nations appear,  and  in  a  majority  of  cases  they  are  chiefly  or  wholly  confined 
to  the  sense  of  hearing :  voices  of  denunciation  or  reproach,  of  threatening,  of 
obscene  allusions, — these  fill  life  with  terror.  Less  common  are  hallucinations 
of  feeling :  insects  crawl  over  the  surface,  snakes  inhabit  the  interior,  unclean 
embraces  terrify  the  nights.  Somewhat  less  frequent  are  hallucinations  of 
taste  :  es])ecially  in  cases  with  delusions  of  poisoning,  the  food  smacks  of  arsenic, 
chloroform,  etc.  The  sense  of  smell  is  sometimes  implicated,  but  it  is  curious 
how  rarely,  except  in  active  delirium,  optical  delusions  appear :  to  hear  the 
])ersecutor  is  most  common,  to  see  him  is  most  rare. 

In  persecutory  paranoia  the  emotional  state  is  one  of  depression,  but  in 
its  depth  and  in  its  relations  this  depression  differs  entirely  from  that  of  true 
melancholia.  The  victim  of  melancholia  believes  himself  worthy  of  all  his 
sorrow — to  himself  acknowledges  his  guilt  and  is  humiliated  by  remorse.  The 
|)aranoiac,  depressed  though  he  may  be  by  his  persecutions,  knows  that  these 
])ersecutions  are  undeserved  and  rebels  against  them.  Again,  except  in  periods 
of  excessive  fury,  the  melancholic  lunatic  is  not  dangerous  to  others,  whilst  the 
paranoiac  is  always  an  object  of  danger  to  his  fellows  :  his  impulse  is  to  resist 
j)ersecution  or  to  revenge  himself  for  wrong,  and  so,  in  self-defence  or  driven 
to  fury  by  a  sense  of  injustice,  he  assaults  his  fancied  persecutor.  The  danger 
is  especially  great  when  the  paranoiac  believes  that  his  persecution  originates 
in  one  individual  ;  nevertheless,  there  is  some  danger  when  the  persecution  is 
thought  to  be  general,  and  at  any  time  the  upbraiding  voice  may,  in  the  mind 
of  the  paranoiac,  attach  itself  to  a  passer-by. 

Closely  allied  to  the  paranoia  just  described  is  that  form  of  the  disorder  in 
which  the  subject  believes  that  his  earthly  possessions  rather  than  himself  are 
attacked  by  mankind.  At  first  quarrelsome  and  litigious  only,  little  by  little 
this  paranoiac,  having  spent  his  time  in  attempts  at  lawsuits,  becomes  when 
these  fail  a  violent  denunciator  of  judges  and  judiciary  systems,  and  finally, 
posing  to  himself  as  a  martyr  or  saint  militant,  fights  society  for  his  own  rights, 
or  perhaps,  taking  a  wider  or  more  ambitious  sweep,  contends  in  every  possible 
way  for  the  general  rights  of  mankind.  At  large  such  paranoiacs  may  be 
anarchist  leaders;  shut  up  in  an  asylum,  they  may  be  most  troublesome  by  their 
efforts  for  liberty  through  the  law. 

Of  difierent  type  is  the  religious  paranoiac.  Almost  invariably  this  mad- 
ness has  blossomed  out  from  an  early  character  of  excessive  piety  and  religious 
zeal,  founded  in  a  great  nuijority  of  cases  on  a  neurasthenic  as  well  as  neuro- 
pathic constitution.  Tn  very  early  life  sedentary  and  retiring  in  habit,  unwill- 
ing and  perchance  unable  to  labor,  careless  of  social  duties,  these  subjects  from 


/'AnA.XOIA.  58a 

the  age  of  puberty  give  themselves  np  to  religion  and  to  onanism,  for  the  rela- 
tion between  religious  and  sexual  ecstasies  is  remarkable,  and  sexual  perversions 
are  in  these  people  very  frequent.  At  last,  when  the  nervous  system  has  been 
weakened  by  fasting,  by  sexual  excess,  by  acute  illness,  or  perchance  without 
apparent  cause,  the  visions  which  constitute  the  pathognomonic  symptoms  of 
the  disorder  appear,  hallucinations  of  sight  being  in  this  form  of  ]iaranoia 
much  more  fre(]uent  than  those  of  other  senses.  The  religious  paranoiac  sees 
the  heavens  open,  the  Virgin  and  the  Son  Himself  smiling  on  him,  or  with 
strange  ecstatic  joy  looks  out  upon  a  procession  of  the  blessed.  I^ater,  voices 
of  rapturous  singing,  of  prophecy,  or  of  commendation,  it  may  be  from  God 
Himself,  add  to  the  overpowering  joy  of  the  vision. 

Egotism  underlies  alike  the  paranoiac  hallucinations  of  persecution  and  of 
ecstasy,  but  in  the  one  case  the  ego  is  the  persecuted  of  mankind,  the  other  the 
praised  of  Heaven.  Often,  however,  the  religious  paranoiac  has  his  depressed 
moments,  when  the  soul  contends  with  devils  for  eternal  salvation. 

Allied  to  religious  paranoia  is  erotic  paranoia,  in  which  the  subject  believes 
himself  to  be  in  love  and  to  be  loved  by  some  person  usually  higher  in  polit- 
ical, professional,  and  social  life.  Such  a  paranoiac  may  spend  the  day  in 
weaving  to  himself  a  romance  of  love  and  the  night  in  erotic  dreams.  Hal- 
lucinations of  hearing  seem  in  this  form  of  paranoia  much  more  frequent  tlian 
those  of  seeing. 

Paranoia  finally  ends  in  a  con<lition  of  mental  enfeeblement,  through  which 
may  be  preserved  much  of  some  peculiar  talent  or  power  ordinarily  possessed. 
Not  rarely,  before  this  stage  is  reached,  the  form  of  the  paranoia  changes. 
Thus,  by  a  gradual  or  by  sudden  transformation  the  persecuted  paranoiac 
becomes  to  himself  the  child  of  fortune,  a  person  of  high  birth,  an  inheritor 
perchance  of  a  throne,  whilst  the  erotic  paranoiac,  disappointed  and  repulsed, 
saddens  into  a  victim  of  undeserved  persecution. 

Diag-nosis. — It  may  seem  easy  to  determine  the  existence  of  an  insanity 
which  is  attended  by  delusions,  but  in  the  case  of  paranoiacs  great  difficulty 
sometimes  arises  in  deciding  how  far  an  opinion  held  should  be  classed  as  a 
belief  or  how  far  as  a  delusion.  This  is  particularly  the  case  when  the  belief 
or  delusion  is  concerning  some  matter  or  matters  which  are  incapable,  from 
their  very  nature,  of  positive  demonstration.  Thus,  in  the  matters  of  relig- 
ious belief  every  man  who  iiolds  strongly  to  a  certain  faith  might  consider 
every  person  who  believes  in  a  ditl'crent  faith  to  be  insane.  The  history  of 
modern  Sj)iritua]ism  seems  to  offer  an  almost  insoluble  ])roblem  :  are  those 
whom  the  mass  of  mankind  believe  to  be  the  dupes  of  modern  Spiritual- 
ism, and  who  themselves  believe  tliat  they  habitually  hold  comnuniion  with 
spirits,  to  be  considered  insane?  AikI  how  far  distant  is  their  mental  j)lane 
from  that  of  the  wom;m  who  is  convinced  that  i'rovideuce  has,  as  the  I'csult 
of  her  prayers,  |)Ut  hack  the  ordinary  course  of  nature,  caused  a  (vclone  to 
cease,  or  ])ut   far   froin    her  an    iiiciirabh'  affection? 

In  a  case  of  which  I  liad  cogni/ance  a  successful  administrator  of  affiii's  of 
moment  and   dctnil    iqiMii    tlic   frontier  oC  (he  United   States  said  to  a    fi'iend  : 


584  MENTAL    DISEASES. 

*'  My  life  in  this  frontier  post,  from  its  monotony,  wonld  be  absolutely  insup- 
portable if  it  were  not  for  my  daily  mail  which  I  get  from  my  dead  friends. 
1  had  a  letter  from  your  brother  last  week,  and  every  morning  I  live  in 
expectation  of  receiving  a  letter  from  some  deceased  friend  or  relative."  The 
letters  really  came  from  a  "medium"  in  the  Eastern  United  States.  On 
another  occasion  the  gentleman  said  :  "  There  is  one  thing  that  gives  me  great 
comfort,  and  that  is  that  I  am  a  descendant  of  the  Virgin  Mary."  Some  one 
intimating  a  doubt  of  that  genealogy,  he  continued  :  "  I  know  that  I  am  a 
descendant  of  the  Virgin  Mary,  because  I  had  a  letter  from  her,  and  she  says 
so ;  and  she  certainly  ought  to  know."  Most  alienists,  I  think,  would  claim 
that  this  man  was  a  paranoiac,  and  yet  how  narrow  is  the  space  between  him 
and  the  ordinary  believer  in  Spiritualism  ! 

The  delusions  of  paranoiacs  may,  on  the  other  hand,  be  so  conformable  to 
what  is  seen  in  ordinary  life  that  the  recognition  of  their  true  nature  becomes 
very  difficult.  I  was  once  met  in  the  boudoir  of  a  palatial  mansion  by  a 
handsome  young  woman,  perfectly  lady-like  and  self-restrained  in  her  man- 
ner, who,  with  much  quiet  show  of  modest  reluctance,  told  me  the  story  of 
her  having  been  infected  with  syphilis  by  lier  husband,  and  of  the  death  of 
their  child  through  the  hereditary  disease.  Thorough  examination  convinced 
me  that  neither  the  woman  nor  the  child  had  had  syphilis.  AVhen  I  assured 
my  patient  that  she  was  not  diseased,  she  expressed  herself  much  relieved,  but 
was  unrelenting  toward  her  husband,  whom  she  accused  of  all  manner  of  in- 
fidelities. At  first  I  entirclv  believed  the  woman's  storv,  but  after  a  time  it 
became  evident  that  her  charges  against  her  husband  were  untrue,  and  that 
she  was  a  paranoiac  with  fixed  sexual  delusions.  This  woman's  intellectual 
powers  were  good,  she  held  her  place  firmly  in  society,  but  a  study  of  her  past 
revealed  abundant  traces  of  the  ungovernable  egotism  w'hich  underlies  much 
of  ]iaranoia. 

Periodical  Insanity. 

Definition. — A  condition  dependent  upon  original  or  acquired  neuropathy, 
in  which  attacks  of  insanitv  occur  at  reo-ular  ov  irreo-ular  intervals. 

In  some  women  the  attacks  of  periodic  insanity  have  a  tendency  to  recur 
at  the  monthly  epoch,  hence  the  so-called  menstrual  insanity.  Epileptic  and 
certain  other  diathetic  insanities  might  well  come  under  the  heading  of  peri- 
odical insanity,  but  for  convenience'  sake  have  been  treated  of  in  otiier  parts. 
(See  page  617.) 

The  cases  of  true  periodical  insanit}'  are  naturally  arranged  for  study  into 
two  classes:  first,  tiiose  in  which  tiie  recurring  attacks  are  of  similar  type; 
second,  those  in  which  the  attacks  vary  in  form. 

In  tlie  first  form  of  periodical  insanity  the  earlier  attacks  may  be  so  light  as 
to  api)arently  differ  from  those  that  follow,  but  when  the  paroxysms  have  once 
been  fully  developed  they  maintain  an  extraordinary  constancy,  even  as  to  the 
details  of  symptoms.  The  same  im])erative  conceptions  and  impulses,  the  same 
delusions,  hallucinations,  and  even  the  same  language,  are  repeated  with  an 


PERIODICAL    IXSANITY.  585 

almost  stereotyped  regularity.  During  the  intervals  the  patient  may  be 
reasonable,  capable  of  attending  to  business,  and  neither  in  eonduct  nor  in 
conversation  give  distinct  evidences  of  his  disease ;  but  usually  a  peculiar 
nervousness,  a  ready  excitability,  a  persistent  hysteria,  or  some  other  distinct 
evidence  of  the  neuropathic  diathesis,  can  be  made  out,  and,  as  the  disease 
advances,  almost  invariably  there  is  a  deterioration  of  character  and  of  mind, 
so  that  even  during  the  intermission  the  individual  is  indifferent,  apathetic, 
with  blunted  emotions  and  decreased  mental  energy,  and  yet,  it  may  be,  at  the 
same  time  more  irascible. 

The  paroxysms  of  periodical  insanity  usually  develop  more  abruptly  than 
do  attacks  of  simple  mania  and  melancholia,  from  which  affections  the  fully- 
developed  periodical  insanity  may  also  usually  be  distinguished  by  the  pres- 
ence of  pronounced  imperative  conceptions,  of  strong  propensities  or  impulses, 
accompanied  by  a  peculiar  perversion  of  the  moral  sense. 

Mania  periodica  may  begin  abrujitly  or  may  be  ushered  in  by  a  very  short 
period  of  depression.  The  peculiarity  of  the  mania  is  that  the  exaltation  is 
accompanied  by  a  peculiar  moral  perversion  which  leads  to  what  is  sometimes 
known  as  the  delirium  of  action.  In  other  words,  the  subject  is  driven  by 
impulses  coming  from  within  to  perform  various  forms  of  impulsive  criminal 
acts — to  steal ;  to  expose  the  person  in  public;  to  commit  sexual  crimes  or  to 
enter  upon  an  orgie  of  sexual  excesses ;  to  burn,  to  wander  from  place  to  place, 
to  commit  murder,  or  to  end  the  scene  by  suicide.  Delusions  are  not  common, 
but  hallucinations  are  more  frequent.  The  mental  distiu'bance  is  often  accom- 
panied by  palpitation,  rushes  of  blood  to  the  head,  cold  extremities,  disturb- 
ances of  secretion,  myosis,  mydriasis,  nystagmus,  insomnia,  loss  of  appetite,  or 
other  evidence  that  the  whole  nervous  system  takes  part  in  the  general  process. 

The  relations  between  the  emotional  exaltation  and  the  morbid  im])ulses 
which  play  so  important  a  role  in  this  form  of  insanity  vary.  Sometimes 
the  mania  predominates,  sometimes  the  imperative  conception  ;  and  under  the 
latter  circumstances  are  developed  those  cases  in  which  criminal  acts  are  per- 
formed by  persons  perhaps  not  otherwise  evidently  insane.  Some  instances  of 
kleptomania  (impulse  to  steal),  of  pyromania  (impulse  to  burn),  and  of  period- 
ical sexual  perversion  come  under  this  variety  of  insanity.  If  the  history  of 
"Jack  the  Ripper"  be  ever  known,  it  will  pr()l)al)ly  be  found  that  the  man  is 
the  victim  of  periodical  mania,  chiefly  showing  itself  in  sexual  perversion,  and 
that  the  murders  which  he  performs  are  in  obedience  to  the  abnormal  sexual 
impulses  and  are  attended  with  a  fin-ious,  almost  cjiiieptic,  orgasm. 

Habitual  drunkenness  is  usually  the  result  of  vice,  (he  habit  having  Ix-cn 
formed  through  self-indulgence  at  a  time  when  the  iini)ulse  to  drink  could 
have  been  resisted  successfully;  but  there  does  a|)pear  to  be  a  neuropathic 
state  in  which  at  intervals  the  subject  is  drawn  by  an  impulse  beyond  his  con- 
trol to  indulge  in  a  narcotic  orgy — a  stale  which  may  properly  be  view(>d  as 
a  periodical  insanity,  to  wliich  the  name  of  (lij)sniii<niiti  is  appliciiblc,  nnd  in 
which  the  law  should  give  authoi-ily  foi-  rcsti;iiiit.  in  one  case  oi'  niy  own  in 
which  the  narcotic   impulse  recurred  at  intervals  circumstances  made  it  possi- 


586  MENTAL    DISEASES. 

ble  to  confine  the  patient,  and  after  some  weeks  of  almost  absolute  insomnia, 
with  furious  struggling  and  almost  manaical  raving,  the  narcotic  impulse  dis- 
appeared without  being  drowned  in  gratification. 

Periodical  Melancholia  is  a  very  rare  affection,  in  which  the  emo- 
tional depression  may  or  may  not  be  accompanied  by  delirium.  The  symp- 
toms may  closely  simulate  those  of  ordinary  melancholia,  except  in  the  great 
constancy  and  severity  of  suicidal  impulses.  The  diagnosis  must  rest  on  the 
recurrence  of  the  attacks. 

In  Circular  Insanity,  or  Cyclothymia,  the  cycles  vary  in  length  from 
a  few  days  to  many  months  :  as  a  general  rule,  the  more  violent  the  symptoms 
the  shorter  is  the  time  required  to  complete  a  cycle.  The  arrangement  of  the 
cycle  varies  in  different  individuals,  but  is  constant  in  the  one  case.  In  this 
wav  a  melancholia  may  be  followed  by  a  mania,  and  this  by  a  lucid  interval, 
or  tlie  mania  may  first  appear,  or  the  lucid  interval  may  follow  the  melancho- 
lia. The  passage  from  one  mental  condition  to  another  may  be  abrupt,  but 
more  commonly  it  is  gradual.  The  mania  may  be  violent,  resembling  in  all 
its  symptoms  an  attack  of  ordinary  acute  mania.  It  may  be  so  mild  as  to 
simply  amount  to  a  condition  of  mental  exaltation  in  which  the  subject  is 
dominated  by  all  sorts  of  immoral  impulses  and  tendencies,  which  lead  to  a 
line  of  conduct  that  has  been  aptly  spoken  of  as  insanity  of  action.  In  like 
manner,  the  melancholia  varies  in  intensity  from  the  most  profound,  hopeless, 
despairing  apathy  to  a  slight  depression  of  spirits.  Sometimes  the  lucid  inter- 
val is  wanting,  and  mania  follows  melancholia  and  melancholia  follows  mania 
in  perpetually-recurring  alternation.  There  are  certain  cases  in  which  the 
symptoms  of  a  circular  insanity  are  so  slight  that  the  patient  does  not  at 
any  time,  to  the  eye  of  the  ordinary  observer,  overstep  the  bounds  of  sanity. 
Such  individuals  are  avoided  by  their  friends  as  moody  and  unreasonable  : 
to-day  sanguine,  talkative,  energetic,  and  extravagant,  to-morrow  they  are 
taciturn,  apathetic,  or  full  of  vain  regrets  for  acts  that  they  have  done  or 
enterprises  that  they  entered  upon   while  in  the  condition  of  exaltation. 

The  individual  attacks  of  circular  insanity  oifer  in  their  symptoms  no 
peculiarities  ;  indeed,  the  mania  or  melancholia  of  a  circular  insanity  seems 
in  every  symptom  to  correspond  to  a  similar  insanity  not  of  the  cyclical 
type. 


FUNCTIONAL  NERVOUS  DISEASES. 

By  HORATIO  C.  WOOD. 


Neurasthenia. 

Definition. — A  condition  of  lack  of  power  of  the  nerve-centres,  not  depend- 
ent upon  the  existence  of  organic  disease  in  any  portion  of  the  body. 

Synonyms. — Nerve-weakness ;  Nerve-exhaustion. 

Etiology. — Neurasthenia  is  not,  in  the  proper  sense  of  the  term,  a  disease, 
but  a  bodily  condition,  which  may  or  may  not  be  secondary  to  organic  diseases 
not  directly  connected  with  the  nervous  system.  The  common  cause  of  primary 
neurasthenia  is  overwork,  combined  with  excessive  mental  emotion,  especially 
of  a  depressing  character,  such  as  anxiety.  The  power  of  creating  nerve- 
energy  varies  indefinitely  in  the  human  individual,  whilst  an  enormous 
expenditure  is  required  for  the  performance  of  the  vital  functions  of  respira- 
tion, circulation,  and  digestion.  There  are  persons  who,  on  account  of  original 
feebleness,  are  scarcely  able  to  afford  the  nerve-force  necessary  for  merely  liv- 
ing— such  persons  are  neurasthenics  from  birth.  Overwork  is  not  an  absolute, 
but  a  relative,  term.  "Whenever  the  daily  expenditure  of  nerve-force  is 
greater  than  the  daily  income,  physical  bankruptcy  and  neurasthenia  must 
result. 

Nervous  exhaustion  may  involve  a  few  nervous  centres,  constituting  a  local 
neurasthenia,  or  may  implicate  the  whole  nervous  system  and  ])roduce  a  general 
neurasthenia.  A  local  neurasthenia  is  always,  however,  attended  by  a  general 
lack  of  tone  and  has  a  great  tendency  to  pass  into  a  general  neurasthenia. 
Sexual  ejjcesses  jiroduce  spermatorrhoea  or  other  forms  of  exhaustion  of  the 
sexual  nerve-centres,  in  most  cases  soon  followed  by  general  neurasthenia, 
constituting  a  group  of  cases  which  may  be  known  as  sexual  neurasthenics. 
Writer's  cramp  is  a  local  neurasthenia  which  I  have  frequently  seen  to  be  the 
herald  of  a  general  breakdown.  Cerebral  asthenia,  the  result  of  mental  over- 
work, commonly  soon  develops  into  general  loss  of  power. 

Symptomatology. — The  symptoms  of  a  developing  neurasthenia  vary 
greatly  in  accordance  with  the  part  of  the  nervous  system  which  is  the  first  to 
give  wav  under  strain.  When  the  overwork  has  been  chiefly  mental,  loss  of 
the  disposition  to  work  is  usually  the  first  symptom,  a  more  and  more  painful 
effort  of  the  will  being  each  day  necessary  for  the  perfi)rmance  of  the  allotted 
task.  The  power  of  fixing  the  attention  upon  the  kind  of  work  which  has 
produced  the  disturbance  is  at  first  interrupted,  but  by  and  by  it  bec^omes  dif- 
ficult to  hold  the  attention  to  any  suijjcct.  Weakness  of  memory,  disturbance 
of  sleep,  sense  of  weight  or  of  constriction  in  the  head,  or  other  abnormal 
sensations  soon  ajjpcar. 


588  FUNCTIONAL   NERVOUS   DISEASES. 

A  developing  local  neurasthenia  may  be  masked,  however,  by  functional 
excitement,  probably  due  to  active  congestion  of  the  nerve-centres.  Tiie 
working  power  of  the  failing  brain  is  often  for  the  time  markedly  increased  : 
the  subject  mav  glory  in  a  wild  intellectual  exaltation,  accompanied  by  an 
uncontrollable  brain-activity,  and  an  almost  complete  insomnia — a  condition 
which  is  prone  to  end  in  some  serious  and  sudden  breakdown. 

Gradual  as  is  the  development  of  the  neurasthenia  in  most  cases,  an  almost 
abrupt  paroxysm  may  occur  after  unnoticed  premonitions.  Thus  I  have  seen 
a  man  fall  in  the  street  with  an  overpowering  vertigo,  the  first  pronounced 
neurasthenic  disturbance. 

In  general  neurasthenia  the  spirits  may  be  moderately  good,  but  usually 
there  is  marked  depression,  which  may  deepen  into  a  decided  melancholy  and 
a  condition  bordering  on  insanity.  The  will-power  becomes  weak,  morbid 
feelings  develop,  and  more  and  more  dominate  the  patient,  who  at  last  may 
become  a  confirmed  hypochondriac.  Neurasthenia  does  not,  however,  often 
lead  to  complete  insanity   unless  there  be  an  inherited  taint. 

Cerebral  asthenia  may  coexist  with  tlie  power  of  enduring  physical  labor, 
but  sooner  or  later  physical  power  fails.  In  this  stage  (or  not  rarely  as  an 
earlier  local  neurasthenia)  weakness  of  sight,  with  loss  of  power  in  the  ocular 
muscles,  often  develops.  The  nature  of  the  optical  trouble  can  usually  be 
recognized  by  noticing  that  vision  is  good  at  the  first  look,  but  fails  when  the 
eye  is  steadily  used  for  a  few  minutes,  although  the  organ  is  optically  perfect. 

Neurasthenic  vaso-motor  weakness  is  often  pronounced.  Excessive  blush- 
ing on  the  sliglitest  provocation,  great  flushing  of  the  face  after  the  use  of 
alcohol  or  other  stomachic  irritant,  waves  of  heat  passing  over  the  body,  occa- 
sional pallors  provoked  by  exertion  or  apparently  causeless,  and  cold  extrem- 
ities,— these  are  some  of  the  phenomena  which  mark  the  lack  of  power  in  the 
centres  tliat  control  the  blood-vessels.  Secretion  also  is  affected.  Night- 
sweats  are  frequent  or  the  hands  and  feet  are  bathed  in  perspiration,  whilst 
any  emotion  or  excitement  produces  a  violent  perspiration  or  often  a  sudden 
diarrhoea. 

Excessive  irritability  of  the  heart  is  very  common  in  neurasthenia.  Exces- 
sive quickness  of  the  pulse,  especially  exaggerated  increase  upon  exertion,  is 
an  ordinary  phenomenon.  Excessive  palpitation,  and  even  pronounced  short- 
ness of  breath,  are  not  rare.  Irregularity  and  intermittency  are  not  rare,  and 
are  usually  especially  pronounced  during  excitement  or  under  the  influence  of 
gastric  or  intestinal  irritation.  When  the  tobacco  habit  has  been  acquired  the 
tobacco  heart  is  almost  always  present.  An  apical  systolic  murmur  may  often 
be  heard,  even  when  there  is  no  distinct  anaemia.  These  murmurs  are  usually 
soft  in  character,  and  may  persist  for  months  without  change.  Often,  but  not 
always,  they  can  be  made  temporarily  to  disappear  by  putting  the  patient  to 
absolute  rest  in  a  horizontal  position. 

Gradnally  the  strength  fails.  Under  the  influence  of  excitement  much 
exertion  may  be  possible  and  not  felt  at  the  time,  although  after  one  or  two 
days  it  is  followed   by  complete  prostration.     Atonic  dyspepsia  is  not  rare. 


XE  URASTHEXIA .  589 

Itching,  formication,  various  paraesthesiae,  violent  neuralgia,  nervous  head- 
aches, often  render  life  a  burden.  Especially  is  neuralgia  prone  to  be  present 
when  the  neurasthenic  is  of  gouty  parentage.  Very  frequently  neurasthenia 
is  the  underlying  foundation  of  hysteria,  and  almost  invariably  in  prolonged 
neurasthenia  there  is  some  hysteria,  so  that  the  line  between  the  neurasthenic 
and  the  hysteric  is  scarcely  more  than  an  imaginary  one. 

Treatment. — In  nervous  exhaustion  recovery  can  onlv  be  obtained  through 
rest  and  food,  aided  by  the  use  of  remedies  for  stimulating  nutrition.  Minor 
disagreeable  symptoms  may  be  met  as  they  arise  by  drugs.  Strychnine, 
arsenic,  and  phosphorus  given  for  a  length  of  time  are  often  of  service  as 
alterative  nutrients,  but  the  chief  reliance  must  be  upon  hygienic  treatment. 

Local  neurasthenia,  whether  existing  by  itself  or  as  the  foundation  of  a 
general  neui-asthenia,  requires  rest  of  the  organ  primarily  worn  out.  Thus  in 
sexual  neurasthenia  sexual  abstinence  is  absolutely  essential.  In  brain-tire  it 
is  the  brain  which  must  be  rested.  To  rest  an  overwearied,  excited  brain  is 
often  not  an  easy  task.  In  attempting  it  the  effort  should  be  to  obtain  the  fol- 
lowing results  :  first,  the  removal  of  all  cares,  anxieties,  and  all  brain-work, 
especially  brain-work  of  such  character  as  has  been  connected  with  the  break- 
down ;  second,  the  maintenance  of  the  interest  of  the  patient,  so  that  the  past 
shall  for  the  time  being  be  forgotten,  and  the  present  not  overweighted  with 
irksomeness;  third,  invigoration  of  the  physical  health  of  the  whole  body,  and 
especially  of  the  nervous  system.  In  order  to  obtain  the  first  of  these  measures 
of  relief  isolation  of  some  sort  is  essential ;  for  the  second,  mental  occupation  is 
usually  required  ;  for  the  third,  fresh  air,  exercise,  or  some  substitute  is  to  be 
suj)cradded  to  abundant  food  and  rest. 

The  proper  method  of  meeting  these  indications  varies  greatly,  not  only 
with  the  varving  physical  conditions  and  idiosyncrasies  of  patients,  but  also 
with  their  diverse  domestic  and  pecuniary  relations.  To  give  detailed  direc- 
tions for  every  case  is  impossible,  and  I  shall  therefore  limit  myself  first  to 
simple  cases  of  brain-tire  in  which  the  muscular  strength  is  preserved  ;  second, 
to  cases  of  profound  general  neurasthenia. 

In  brain-tire  travel  is  usually  recommended,  and  travel  affords,  when  ])rop- 
erly  directed,  separation  from  old  cares  and  thoughts,  a  maintenance  of  interest 
by  a  succession  of  novel  sights  and  experiences,  and  the  physical  stimulation 
of  fresh  air  and  exercise.  In  bad  cases  general  travel 'is  too  stinudating. 
Ocean- voyaging  gives  complete  isolation,  fresh  air,  mental  stagnation,  and,  if 
the  patient  be  fond  of  the  sea,  complete  enjoyment.  Camping  in  the  wilder- 
ness offers  also  all  of  these  advantages,  and  as  a  further  good  the  possibility  of 
obtaining  exercise  in  exactly  the  amount  desired.  The  subject  may  liv(>  in  his 
tent  and  be  nursed  and  fed  by  his  guide  or  may  do  the  work  of  a  day-laborer. 
Quiet  travel  in  the  mountainous  distri(!ts  of  foreign  countries  is  often  V(M-y 
efficient,  but  sight-seeing,  and  even  visiting  cities,  must  be  avoided.  The  (piicl 
of  Switzerland  or  the  Tyrol  may  bring  restoration  when  the  bustle  of  Ijondon 
and  Paris  might  complete  the  ruin.      In  all  cases  strict  attention  must  be  paid 


590  FUNCTIONAL    NERVOUS   DISEASES. 

to  the  individual  tastes  of  the  sufferer  in  deciding  what  measures  should  be 
carried  out. 

There  are  cases  of  neurasthenia  in  which  the  slightest  exercise,  or  even  the 
unconscious  effort  and  excitement  of  seeing  personal  friends,  is  an  injury.  In 
these  cases  the  so-called  "  rest-cure  "  often  acts  most  beneficially.  Rarely  does 
it  itself  give  permanent  relief,  but  it  often  lays  the  foundation  for  later  com- 
plete restoration  by  means  of  outdoor  life  and  exercise  taken  after  a  certain 
amount  of  strength  has  been  gained.  A  word  of  caution  seems  necessary 
ao-ainst  the  routine  employed  in  this  rest-cure.  It  is  simply  the  carrying  out 
of  a  principle,  and  although,  in  the  pages  of  a  book  like  this,  it  is  necessary 
to  give  a  fixed  formula,  success  in  practical  life  will  depend  upon  the  skill  of 
the  practitioner  in  modifying  this,  and  adapting  formulae  to  the  needs  of  the 
individual  case.  The  principles  of  the  rest-cure  are  absolute  rest,  forced  feed- 
infT,  and  passive  exercise.  The  rest  must  be  for  the  mind  as  well  as  for  the 
bodv,  so  that  in  severe  cases  complete  and  absolute  isolation  must  be  insisted 
upon  :  and  especially  when  there  is  a  decidedly  hysterical  element  is  it  necessary 
to  separate  the  patient  entirely  fi'om  her  friends.  Under  these  circumstances 
there  must  be  a  well-trained  nurse  who  is  personally  agreeable  to  the  patient. 
The  confinement  would  be  very  irksome  to  any  except  the  most  exhausted 
jiatient  were  it  not  for  the  daily  visits  of  those  engaged  in  the  treatment.  To 
further  provide  against  ennui  the  nurse  should  be  a  good  reader,  so  that  under 
the  definite  instructions  of  the  physician  she  can  occupy  a  certain  portion  of 
the  time  in  reading  to  the  patient.  In  the  worst  cases  the  patient  should  not 
feed  himself  or  iierself  or  perform  any  of  the  acts  of  the  toilet.  Directly  after 
breakfast  the  sponge-bath  should  be  given  by  the  nurse,  the  patient  being  be- 
tween blankets.  Hot  water  should  be  used  or  hot  sea-brine,  and  after  each 
part  has  been  sponged  over  it  should  be  momentarily  rubbed  with  a  piece  of 
ice,  followed  by  brisk  friction  with  a  Turkish  towel.  The  greatest  care  should 
be  given  to  the  question  of  feeding.  The  end  to  be  attained  is  to  give  as  much 
food  as  can  be  digested  without  overdoing  and  deranging  digestion.  It  is 
usually  better  to  give  the  food,  which  must  be  both  light  and  nutritious,  at 
short  intervals.  In  most  cases  milk  should  be  used  very  largely,  sometimes 
exclusively.  Often,  especially  when  there  is  a  tendency  to  obesity  or  when  the 
digestive  powers  are  feeble,  the  milk  should  be  skimmed.  Frequently  koumiss, 
matzoon,  or  other  fi^rmented  milks  are  advantageous.  Rarely  peptonized  milk 
may  be  given.  Beef  and  other  concentrated  meat-essences  are  valuable  as  stim- 
uhuits,  and  may  be  used,  especially  as  the  basis  of  soujjs.  Various  farinaceous 
arti(;les  of  food  may  be  added  to  them,  or  if  an  egg  be  broken  into  the  concen- 
trated bouillon  or  beef-essence  just  as  it  ceases  boiling,  a  nutritious,  and  to  many 
])ersons  pahitable,  dish  is  obtained.  When  constipation  exists,  oatmeal  porridge, 
Graham  bread,  fresh  or  dried  fruits  may  be  allowed  if  readily  digested  by  the 
patient.  In  order  to  give  a  general  plan  of  tiie  dietary  the  following  schedule 
of  the  daily  life  is  given.  Such  a  schedule  should  always  be  put  into  the  hands 
of  the  nurse,  who  should  be  required  to  follow  it  strictly.  It  must  be  altered 
from  day  to  day,  so  as  not  to  weary  the  patient  with  monotony.    It  is  especially 


1 


KEURASTJIEXrA.  591 

important  to  remember  that  the  diet  must  be  carefully  studied  for  each  patient, 
and  be  adapted  to  the  individual  requirements  of  the  case.  Success  will  in  a 
great  measure  depend  upon  the  practical  skill  and  tact  of  the  physician  in  this 
adaptation  : 

8  a.  m.  Rolls  or  toast;  cocoa  or  weak  coffee,  or  roasted  wheat  coffee; 
beefsteak  tenderloin  or  mutton  chop. 

9  A.  M.     Bathinff. 

1  1  A.  M.     Oatmeal  porridge,  with  milk,  or  else  a  pint  of  koumiss. 
12  M.     Massage. 

2  P.  M.  Dinner :  bouillon  with  or  witlu)ut  ey-y: ;  beefsteak  ;  rice ;  roast 
white  potatoes ;  dessert  of  bread-pudding,  blanc  mange,  or  similar  farinaceous 
article  of  diet. 

4  P.  M.      P^lectricity. 

5  P.  M.     Milk  toast. 

9  P.  M.     Half  pint  of  skimmed  milk  or  koumiss. 

In  many  cases  the  patient  at  first  can  take  very  little  food,  and  it  is  very 
frequently  best  to  begin  the  treatment  with  an  entirely  liquid  diet,  giving  milk 
every  two  hours  or  using  Liebig's  raw-meat  soup,  with  milk  or  plain  farinaceous 
food,  and  (nily  after  a  time  gradually  accustoming  the  patient  to  solid  food. 
Not  rarely  a  prolonged  milk-diet  is  of  great  service.  The  rest-cure  is  indeed 
largely  ba-^ed  upon  a  careful  regulation  of  the  food ;  but  a  full  discussion  of 
the  various  dietaries  to  be  used  would  require  a  treatise  upon  dietetics. 

Exercise  is  of  value  in  health  by  its  stimulating  the  general  nutrition,  aid- 
ing the  flow  of  blood  back  to  the  heart,  and  increasing  the  excrementitious 
output  from  the  emunctories.  In  the  rest-cure  these  effects  are  obtained  in  a 
more  or  less  imperfect  manner  without  the  expenditure  of  the  patient's  nerve- 
force  by  the  use  of  electricity  and  massage.  The  electrical  current  })roduces 
not  only  muscular  contractions,  but  probably  affects  the  tone  of  the  minute 
blood-vessels.  Its  action  is  so  decisive  that,  as  has  been  shown  by  Dr.  S.  Weir 
Mitchell,  it  M  ill  often  temporarily  elevate  the  temperature  of  the  whole  body. 
The  faradic  current  alone  is  used.  It  is  applied  in  two  ways :  first,  to  the 
individual  muscles  ;  second,  to  the  whole  bodv.  The  stances  should  be  dailv, 
the  operator  beginning  at  the  hand  or  foot  and  systematically  faradizing  each 
muscle  of  the  extremities  and  trnidv.  The  slowly-interrupted  current  is  gen- 
erally preferable,  l)ut  advantage  is  sometimes  gained  by  varying  the  raj)idity 
of  the  interruj)tions.  The  general  rule  is  to  select  that  current  which  produces 
most  muscular  contraction  with  the  least  pain.  The  poles  should  be  applied 
successively  to  the  n)otor  points  of  the  muscles,  so  as  to  contract  each  firmly 
and  thoroughly.  This  process  should  occupy  from  thirty  to  forty  minutes. 
The  electrodes  are  th(.'n  to  be  replaced  by  large  sj)onges  well  damj)ened  with 
salt  water:  one  of  these  should  be  ])laced  at  the  nape  of  the  neck  and  fhc  other 
against  the  soles  of  the  feet,  and  a  ra|)idly-interriiptcd  current,  as  strong  as  ihc 
]>atient  can  bear,  should  be  sent  through  tlu;  body  for  twenty  minutes  or  half 
an  hour.  In  some  cases  the  ele(;trical  j)rogrammc  may  be  varied  so  as  to  get 
a  local  stimulant  action  from  the  general  current;  thus,  when  the  digestion  ia 


5S2  FUNCTIONAL    NERVOUS  DISEASES. 

enfeebled  and  the  bowels  costive,  for  a  portion  of  the  time  one  of  the  sponges 
may  be  placed  upon  the  epigastric  region.  In  women,  when  there  is  great 
abdominal  and  pelvic  relaxation,  one  pole  may  be  placed  high  up  in  the  vagina. 
I  have  seen  long-standing  uterine  prolapse  cured  in  this  way.  Some  electro- 
therapeutists  claim  great  advantage  from'galvanization  of  the  cervical  sym- 
pathetic ganglia,  but  I  do  not  myself  believe  that  they  have  ever  succeeded 
in  reachino;  these  o-anglia  with  the  current. 

Massage,  like  electricity,  affects  greatly  the  peripheral  circulation,  empties 
the  juice-channels,  and  gives  tone  to  the  muscular  system.  It  must  be  clearly 
distino-uished  from  rubbing  of  the  skin.  It  consists  in  manipulations  of  such 
of  the  muscles  as  are  not  too  deep  to  be  reached,  and  of  the  cellular  tissue.  In 
order  to  lessen  as  much  as  may  be  the  skin-friction  by  these  manipulations,  it 
is  often  well  to  anoint  the  surface  with  cocoanut  or  other  bland  oil.  In  })rac- 
tisino-  massage  it  is  essential  to  remember  that  the  natural  course  of  the  venous 
l)lood  and  the  juices  of  the  cellular  tissue  is  toward  the  centre  of  the  body  ; 
therefore  all  general  massage  movements  should  be  practised  in  this  direction. 
The  manipulations  are  percussion,  rolling,  kneading,  and  spiral.  They  consist 
of  movements  made  with  the  pulpy  ends  of  the  fingers  and  thumbs,  and  spiral 
movements  with  the  whole  hand  so  folded  as  to  adapt  its  palm  to  the  limb. 
In  percussion  the  strokes  should  be  from  the  wrist  and  should  be  quick  and 
short.  It  is  probably  not  possible,  even  by  long,  strong  strokes,  to  affect  deep 
muscles.  In  the  rolling  manipulations  the  effort  is  to  roll  the  individual 
muscles  beneath  the  pulps  of  the  fingers.  This  manipulation  may  be  varied 
by  pinching  the  muscles,  not  the  skin,  and  kneading.  In  each  case  it  is  inter- 
mittent pressure  upon  the  muscles  that  is  aimed  at.  The  circular  movements 
are  to  be  in  opposite  directions  with  both  hands  simultaneously,  the  limb  being 
grasped  by  one  hand  a  little  above  the  other,  and  a  spiral  sweep  made  up  the 
limb,  the  ball  of  the  thumb  and  the  palm  of  the  hand  resting  upon  the  patient, 
and  the  pulpy  parts  of  the  thumb  and  the  fingers  grasping  the  limb.  It  is 
especially  such  motions  as  these  which  affect  the  circulation  of  the  flesh-juices. 

The  length  of  time  in  which  a  patient  should  be  kept  in  bed  varies  from 
three  to  six  weeks.  The  getting  up  should  be  gradual,  the  time  of  sitting  up 
and  the  amount  of  exercise  carefully  increased  from  day  to  day.  The  electrical 
treatment  should  be  rapidly  withdrawn,  but  often  massage  may  be  continued 
with  advantage  every  other  day  for  some  time.  So  soon  as  can  be  the  patient 
should  be  sent  out  of  the  city,  to  consolidate  by  outdoor  life  that  which  has 
been  gained. 

Hysteria. 

Definition. — A  functional  disorder  of  the  nervous  system,  characterized  by 
depression  of  the  will-power,  exaltation  of  the  emotional  nature,  and  an  infin- 
itude of  shifting,  polymorphic  nervous  disturbances  more  or  less  clearly  simu- 
latino;  various  organic  diseases. 

Etiology. — Although  the  name  "hysteria"  is  derived  from  the  Greek 
uarepo^,  a  womb,  there  is  no  direct  connection  between  the  disease  and  the 
sexual  organs,  except  only  through  the  tendency  of  sexual  disturbances,  and 


HYSTERIA.  593 

» 
especially  sexual  excesses,  to  produce  nervous  exhaustion  and  irritation,  which 
iu  turn  may  aid  in  the  development  of  hysteria.  The  aifection  is  vastly  more 
common  in  females  than  in  males,  simply  because  the  nervous  system  of  the 
female  is  less  robust,  more  excitable,  more  sensitive,  and  more  readily  thrown 
off  its  balance  than  is  that  of  the  male.  Race  and  racial  habits  are  of  oven 
more  importance  than  sex  as  an  etiological  factor.  In  barbarous  countries  the 
disease  is  practically  unknown.  In  Northern  races,  with  a  tendency  to  phleg- 
matic temperament,  hysteria  is  comparatively  infrequent  and  of  minor  severity, 
whilst  the  mobile  Southern  temperament  favors  its  development.  Thus  the 
Latin  races,  as  exemplified  in  the  French  and  Italian,  are  much  more  hysterical 
than  the  English  and  Teutonic,  and  in  the  extreme  southern  portion  of  the 
United  States,  where  the  Latin  blood  predominates,  severe  hysteria  is  much 
more  frequent  than  in  the  North. 

In  the  majority  of  cases  the  disease  first  manifests  itself  between  fifteen  and 
twenty-five  years  of  age,  but  it  is  not  rare  before  puberty,  and  occasionally 
occurs  even  in  very  young  children.  I  have  seen  it  in  young  boys  as  fre- 
quently as  in  young  girls.  In  boys  it  is  often  connected  with  or  dependent 
upon  masturbation,  adherent  prepuce,  or  other  irritation  of  the  sexual  organs. 

The  influence  of  heredity,  especially  neuropathic  heredity  rather  than 
direct  heredity,  in  the  production  of  hysteria  is  very  great,  whilst  education 
and  habits  of  life  are  almost  equally  powerful.  liuxury,  license,  and  indul- 
gence during  childhood,  indoor  rather  than  outdoor  life,  any  method  of  edu- 
cation or  of  life  which  renders  the  nervous  system  more  sensitive  and  less 
robust,  tend  very  strongly  to  the  development  of  the  hysterical  temperament. 

Hysteria  may  unexpectedly  appear  as  the  result  of  nervous  exhaustion 
produced  by  overwork,  depressing  emotions,  long-continued  severe  pain,  or 
exhausting  dissipation.  Moral  influences  are  often  very  effective  in  their 
action  in  persons  of  nervous  temperament.  The  disease  not  rarely  illustrates 
the  contagiousness  of  example  :  a  single  hysterical  patient  will  sometimes 
inoculate  a  Avhole  school,  infirmary,  or  hospital  ward,  transforming,  it  may 
be,  the  quiet  retreat  or  educational  institution  into  a  pandemonium  of  nervous 
explosions.  During  the  ]Middle  Ages,  wlien  by  misery,  poverty,  and  religious 
excitement  the  ground  had  been  especially  prepared,  whole  communities  became 
involved  in  epidemics  of  hysterical  madness  ;  hence  the  Flagellants,  Children's 
Crusade,  etc. 

When  the  hysterical  temperament  exists,  local  iiijiuy  or  local  disease  is 
prone  to  bring  about  a  local  hysteria  in  the  aflccted  part,  and  when  the 
original  local  disease  is  of  such  character  as  to  wear  heavily  upon  the  general 
nervous  system,  local  hysterical  manifestations  nuiy  devcloj)  after  :ni  organic 
lesion  or  disease  in  a  person  who  previously  had  not  shown  any  distinct  hys- 
terical symptoms. 

Symptomatolog-y. — The  symptoms  of  hysteria  are  so  infinite  in  their 
numl)er,  their  variety,  and  their  collocation,  the  liisloiy  of  hysterical  cases  is 
so  widely  diverse,  the  course  of  the  disease  is  so  al)soliil(lv  without  rule,  that 
it  seems  impossible  to  give  any  concise  dcscri|)tion  of  the  alTcction  within  the 

^■(.i..  I.— .'{8 


594  FUNCTIONAL    NERVOUS  DISEASES. 

space  allotted  in  this  volume.  It  must  be  remembered  that  hysteria  exists  in 
nature  in  every  possible  degree,  and  that  the  majority  of  cases,  as  seen  in  this 
country,  are  those  of  minor  hysteria,  grading  up  from  the  slightest  hysterical 
tinge  in  temperament  or  in  disease.  It  must  also  be  borne  in  mind  that  the 
ingrained  hysteria  due  to  heredity  is  far  deeper  in  its  seat  than  what  may  be 
known  as  accidental  hysteria ;  that  is,  the  hysterical  condition  developed  by 
the  accidents  of  life.  Under  the  latter  circumstances  the  ordinary  signs  of 
hysterical  temperament  are  often  wanting. 

Hysteria  often  reveals  itself  in  certain  physical  peculiarities :  the  large, 
full,  liquid  eye,  the  mobile  pupil,  the  clear  skin,  the  vivacious  movement  of 
ever-changing  whims,  or  the  slow,  languid  movements  of  the  self-conscious 
beauty  may  furnish  unmistakable  signs  of  the  hysterical  temperament. 

Mental  Symptoms. — The  basis  of  the  hysterical  character  is  selfishness — a 
selfishness  which  sometimes  shows  itself  in  the  indulgence  of  the  grosser  appe- 
tites and  desires,  but  which  more  commonly  seeks  self-gratification  in  applause, 
in  admiration,  and  in  being  the  centre  of  sympathetic  attention.  Indeed,  this 
selfishness  often  leads  its  possessor  to  great  lengths  of  apparent  self-sacrifice, 
the  desire  for  praise  and  attention  overmastering  sensibility,  pain,  and  even 
present  contumely.  The  hysterical  woman  is  self-conscious  and  self-centred, 
dwelling  ever  on  her  own  personality,  its  needs,  its  wishes,  its  life,  its  ailments, 
its  everything.  Excessive  sensitiveness  in  all  that  regards  herself  is  the  nat- 
ural outcome  of  this  mental  state.  Self-indulgence  goes  hand  in  hand  with 
self-consciousness,  while  the  will  is  without  power  to  assert  itself  and  the  indi- 
vidual knows  not  at  all  the  path  of  self-control  and  true  self-sacrifice. 

The  weakness  of  the  will  is  not  the  cause  of  the  mental  attitude,  but  only  one 
of  the  concomitants  :  unwillingness  to  make  the  effort  necessary  for  self-con- 
trol leaves  the  individual  largely  to  the  play  of  outside  forces,  especially  when 
these  forces  touch  aright  the  dominant  chords  of  character.  Hence,  sugges- 
tions of  conduct,  sympathy  with  suffering,  and  even  questions  as  to  symptoms, 
have  an  inordinate  influence.  The  pain  that  is  not,  when  asked  for  soon 
becomes. 

The  morbid  desire  for  attention  and  sympathy  leads  to  intentional  simula- 
tion of  disease,  so  that  the  hysteric  will  pretend  what  does  not  exist,  but  the 
mimicry  of  disease  in  hysteria  has  in  the  majority  of  cases  a  deeper  seat  than 
this.  It  is  an  unconscious  simulation.  Not  merely  do  emotions  dominate  the 
forces  of  life,  but  ideas  formed  in  the  mind  may  express  themselves  in  a  phys- 
ical enactment  of  a  disease  which  has  been  thought  of.  The  dread  of  some 
disorder,  or  of  the  disablement  and  suffering  which  it  causes,  is  almost  as 
powerful  as  desire  in  multiplying  the  symptoms  of  an  hysteria. 

A  very  extraordinary  ruj)ture  often  takes  place  in  hysteria  between  con- 
sciousness and  will.  Thus  I  have  seen  a  patient  declare  that  she  could  not  see 
with  the  left  eye,  and  yet  respond  correcstly  to  every  test  for  the  existence  of 
blindness  in  the  affected  eye  until  the  separate  prisms  were  used  after  she  had 
been  told  that  prisms  make  a  person  see  double  with  one  eye.  Under  this 
belief  the  double  images  were  seen  and  located  correctly,  proving  that  there 


lIYSTEJilA.  505 

was  vision  all  the  time  with  the  left  eye.  I  do  not  believe  that  the  patient 
purposely  lied  throughout,  but  that  the  belief  that  she  could  not  see  in  the  left 
eye  so  dominated  conscious  perception  that  there  really  was  no  consciousness 
of  the  image  until  belief  in  that  image  was  established. 

Emotional  instability,  lack  of  control  of  the  will  over  the  emotional  nature, 
is  one  of  the  most  characteristic  manifestations  of  the  hysterical  state.  With 
or  without  reason,  but  always  withont  control,  the  subject  laughs  and  cries, 
the  emotional  storms  rising  rapidly  from  the  most  inadequate  causes. 

The  desire  for  sympathy  leads  always  to  exaggerated  statements,  and  in  the 
examination  of  an  hysteric  this  must  always  be  borne  in  mind.  It  leads  also 
to  innumerable  forms  of  deception.  Thus  I  have  known  an  hysterical  woman 
to  raise  an  alarm  in  her  country-house,  and  be  found  upon  the  ground  beneath 
an  open  window,  apparently  greatly  injured  by  the  fall  which  she  asserted  she 
had  received  during  a  somnambulistic  walk,  when  in  truth  she  had  simply 
walked  out  of  the  door  and  laid  upon  the  grass.  Especially  common  is  it  for 
these  simulated  symptoms  to  take  a  shape  that  will  bring  great  personal  atten- 
tion by  the  young  and  inexperienced  physician,  and  mayhap  minister  to  the 
morbid  sexual  desire  of  the  patient.  To  swallow  pins  and  needles,  or  to  thrust 
them  into  the  tenderest  parts  of  the  body  that  they  may  be  withdrawn  by  the 
doctor,  is  common  enough.  To  retain  urine,  with  absolute  recklessness  of  the 
suffering  involved,  for  two  or  three  days,  that  the  catheter  may  be  used,  is  very 
frequent.  I  have  seen  the  rectum  and  lower  large  intestine  secretly  filled  day 
after  day  with  starch  jellies,  to  the  utter  astonishment  of  the  practitioner, 
especially  when  the  true  nature  of  the  fsecal  discharge  was  revealed  by  the 
microscope  of  the  consultant.  A  very  common  trick,  which  imposes  with 
extraordinary  frequency  upon  the  credulity  of  doctors,  is  the  placing  of  small 
bones  by  the  woman  over  night  in  the  uterus,  to  be  removed  by  the  doctor  tlie 
next  day  as  parts  of  a  dead  foetus. 

Disturbances  of  Consciousness  and  Motion. — Besides  the  major  and  minor 
hvsterical  paroxysms,  spasms,  choreic  movements,  and  paralytic  disturbances 
occur  in  hysteria.  The  hysterical  spasms  may  be  localized  in  any  portion  of 
the  l)ody  ;  the  choreic  movements  are  sufficiently  described  elsewhere  in  this 
book.     (See  page  634.) 

Into  mino7'  hysterical  paroxysms  enter  all  the  elements  of  the  major  affec- 
tion, but  usually  some  of  the  symptoms  are  wanting  in  individual  attacks,  and 
not  rarely  a  single  stage  constitutes  the  whole  paroxysm.  The  aura  is  not 
usually  present,  unless  the  so-called  globus  In/dericus  (a  sense  of  constriction 
or  the  rising  of  a  ball  in  the  throat)  be  considered  to  represent  it.  The  emo- 
tional state  is  usually  well  devcl(>ped,  and  is  especially  prone  to  express  itself 
by  uncontrollable  laughter  or  equally  nncontrollable  sobbing  or  crying.  A 
very  characteristic  performance  which  I  have  seen,  especially  in  children,  is 
that  which  may  be  termed  beast-mimicru,  in  wiiich  the  patient  bites  or  snaps 
or  snarls  like  a  do-r  or  crows  like  a  cock,  or  in  st)nie  other  way  imitates  the 
movements  and  the  vocal  acts  of  the  lower  animals.  Among  these  cases 
belong  the  nr)t  rare  attacks  of  spurious  /ii/(lrnj)liobi(i,   in   which,  cither  with 


596  FUNCTIONAL    NERVOUS   DISEASES. 

or  without  severe  general  convulsioo,  the  subject  shows  profound  dread  of 
water,  great  emotional  disturbance,  often  crying  out  to  be  held  lest  he  bite 
some  person,  and  continually  snarls  and  barks  and  attempts  to  bite.  These 
symptoms  do  not  closely  resemble  those  of  true  hydrophobia,  in  which  disease 
the  subject  never  offers  to  bite,  and  does  not  make  any  noises  resembling  those 
of  the  dog  or  any  other  lower  animal.  Beast-mimicry  may  be  considered  as 
diagnostic  of  hysteria. 

The  convulsive  symptoms  of  minor  hysteria  are  tonic  i-ather  than  clonic. 
More  or  less  persistent  rigidity  is  very  frequent  and  very  characteristic.  It 
may  last  for  hours  or  may  pass  by  in  a  few  mornents.  The  disturbances  of 
consciousness  are  similar  to  those  of  major  hysteria  (see  page  598),  only  usually 
less  severe. 

In  the  major  hysterical  convulsion  the  tendency  is  to  rigid  contractions  of 
muscles  which  lock  the  body  in  positions  like  those  of  voluntary  life.  Con- 
sciousness may  be  abolished,  but  is  usually  only  perverted.  Thus  a  patient, 
apparently  unconscious  during  the  fit,  narrates  after  recovery  all  that  has 
occurred  during  the  paroxysm  ;  or  there  may  be  the  so-called  automatic  con- 
sciousness, in  which  the  patient  during  the  paroxysm  seems  to  understand  all 
that  is  said,  but  nevertheless  after  the  paroxysm  has  no  remembrance  of  what 
has  taken  place. 

Commonly  the  major  convulsion  is  preceded  by  some  warning,  such  as  a 
special  feeling  of  malaise,  epigastric  sensation,  palpitation  of  the  heart,  gid- 
diness, globus  hystericus,  or  an  aura  which  appears  to  arise  from  a  hyperses- 
thetic  ovary.  The  patient  falls,  but  usually  gently  and  not  with  the  sudden- 
ness of  true  epilepsy.  Not  rarely  there  is  at  this  time  an  initial  scream,  which 
may  be  repeated  during  the  paroxysms.  The  pallor  of  the  face  may  now  be 
marked.  A  simple  tonic  spasm  develops,  lasting  two  or  three  minutes;  In  it 
the  limbs  are  usually  rigid,  with  the  toes  pointed  downward  and  the  arms 
extended  or  lying  at  the  side  of  the  patient.  It  is  at  this  period  that  the  res- 
piration becomes  arrested,  and  there  is  developed  the  stage  of  asphyxia  of 
some  writers.  The  face  is  swollen,  with  turgid  veins,  and  suffocation  seems 
imminent.  This  condition  may  be  followed  by  a  furious  clonic  convulsion,  in 
which  bloody  foam  gathers  about  the  mouth,  although  the  movements  pre- 
serve, to  some  extent,  the  appearance  of  wilfulness,  and  the  head  or  the  arms 
are  struck  violently  and  with  seeming  purposiveness  against  the  floor  or 
dashed  against  pieces  of  furniture.  Following  these  clonic  convulsions,  or 
not  rarely  replacing  them,  is  the  characteristic  stage  of  opisthotonos,  in  which 
the  person  lying  upon  the  back  is  bent  violently  into  the  arc  of  a  circle,  so 
that  the  body  rests  upon  the  head  and  feet,  with  the  central  portion  arched 
from  the  ground.  The  muscular  contractions  may  be  so  severe  that  the  head 
is  drawn  completely  backward  and  the  upper  portions  of  the  body  rest  upon 
the  face,  which  looks  toward  the  floor,  whilst  the  lower  end  of  the  arc  is  sup- 
ported on  the  toes.  This  condition  of  opisthotonos  may  last  for  some  minutes. 
In  some  cases  it  is  interrupted  or  replaced  by  violent  purposive  clonic  spasms, 
the  patient  suddenly  leaping  from  the  bed  or  rising  into  a  sitting  position,  and 


HYSTERIA.  597 

as  quickly  falling  back  again  in  opisthotonos.  This  to-and-fro  movement  may- 
take  place  with  extraordinary  velocity.  In  some  cases  the  body  is  bent 
violently  laterally  instead  of  backward.  The  opisthotonio  stage  may  be  inter- 
rupted by  various  emotional  actions,  or  it  may  gradually  subside  into  what 
may  be  called  the  emotional  stage,  when  the  patient  assumes  some  attitude  of 
intense  emotion,  and  not  rarely  the  so-called  posture  of  the  crucifix,  in  which 
the  subject  lies  upon  the  back,  absolutely  quiet,  with  the  legs  stretched  out 
side  by  side  and  the  arms  firmly  extended  at  right  angles  to  the  body  in  the 
position  of  a  cross.  The  widely-opened  eyes,  with  dilated  pupils,  appear  to 
be  looking  into  indefinite  distance,  whilst  a  beatific  smile  is  settled  upon  the 
face,  so  that  by  the  ignorant  the  convulsant  is  often  believed  to  be  seeing 
visions  of  heavenly  joy.  Usually  the  emotion  changes  from  time  to  time  :  the 
light  of  religious  beatitude  upon  the  countenance  deepens  into  an  intense 
voluptuousness,  attended,  it  may  be,  with  lustful  words  and  gestures;  or  ter- 
ror becomes  supreme,  and  is  manifested  with  equal  intensity  ;  or,  in  a  passion 
of  penitence,  the  convulsant,  with  sobs,  bitter  cries,  and  broken  words,  begs 
for  mercy.  Again  the  scene  shifts,  and,  now  singing,  now  weeping,  reproach- 
ing alternately  herself  and  her  care-takers,  the  woman  passes  on  to  a  slowly- 
perfected  consciousness. 

Hallucinations  occur  during  and  after  the  fit,  and  are  always  correlated  to 
the  emotional  state.  Thus  during  the  terror  the  subject  sees  rats  and  other 
disgusting  objects,  which,  according  to  Charcot,  are  usually  upon  the  side  that 
is  anaesthetic  between  the  paroxysms. 

The  character  and  mental  states  of  the  confirmed  hysteric  approach  in  many 
respects  those  of  a  paranoiac  (see  Hysterical  Insanity,  p.  558),  whilst  the  de- 
lirium of  a  major  hysterical  paroxysm  may  simulate  an  acute  mania.  I  have 
indeed  seen  recurring  attacks  of  hysterical  epilepsy  replaced  by  a  furious  out- 
break of  acute  mania,  lacking  in  none  of  the  symptoms  characteristic  of  that 
disease.  It  seems  to  me  that  in  such  a  case  the  maniacal  explosion  must  be 
looked  upon  as  the  direct  outcome  of  the  hysterical  neurosis,  and  that  there- 
fore the  existence  of  an  hysterical  acute  mania  not  in  itself  distinguishable 
from  ordinary  acute  mania  must  be  acknowledged.  In  most  cases  in  which 
such  maniacal  symptoms  exist  the  neurosis  is  so  thoroughly  engrafted  upon 
the  constitution  that  permanent  recovery  is  not  possible,  the  patient  during  life 
suffering  from  various  forms  of  hysterical  attack,  and  being  always  possessed 
of  the  peculiarities  which  have  already  been  spoken  of  as  characteristic  of  the 
hysterical  temperament.  Plysterical  symj)toms  may  occur  during  almost  any 
form  of  insanity,  but  do  not  warrant  our  looking  upon  such  a  melancholia  or 
mania,  or  whatever  form  the  affection  may  take,  as  hysterical,  scarcely  more 
tlian  we  should  be  warranted  in  considering  pneumonia  when  associated  with 
hysterical  symptoms  as  hysterical.  At  the  same  time,  the  relation  of  the 
hysterical  temperament  to  monomanias  and  to  general  insanities  is  distinct; 
and,  according  to  iiiv  belief,  it  is  entirely  possil)le  for  any  form  of  insanity  to 
be  simulated  by  symj)toms  wliieh  have  their  origin  in  the  original  faulty  organ- 
ization that  is  file  basis  oi'  elii'onic  hysteria  ;    moreover,  such    faulty    nerve- 


598  FUNCTIONAL    NERVOUS   DISEASES. 

organization  is  closely  allied  to  the  peculiar  neurotic  temperament  which  is  the 
basis  of  much  insanity. 

Closely  allied  to  the  major  hysteria  is  hysterical  somnolence,  which  may 
take  the  form  of  a  true  narcolepsy  (the  patient  being  continually  drowsy,  fall- 
ing asleep  at  all  times,  but  passing  only  the  nights  in  profound  slumber),  or  it 
may  assume  the  shape  of  the  lethargy  or  trance. 

Hysterical  trance  usually,  but  not  always,  commences  with  marked  hyster- 
ical symptoms  which  leave  the  subject  in  absolute  repose.  The  face  may  be 
red  and  hot,  especially  in  the  first  days  of  the  attack,  but  usually  it  is  pale. 
The  pulse  at  first  may  be  regular  and  slow,  but  after  a  long  sleep  it  is  rapid 
and  feeble.  The  respirations,  generally  quiet,  may  at  times  become  hurried, 
irregular,  and  even  stertorous.  In  severe  cases  the  movements  of  the  thorax 
may  be  so  slight  as  to  be  traceable  with  difficulty.  The  muscular  system, 
often  thoroughly  relaxed,  may  be  rigid,  and  in  many  cases  muscular  relaxation 
alternates  with  muscular  contractions  or  even  contractures.  The  eyes  are 
opened  or  closed  ;  very  frequently  minute  tremors  affect  both  the  lids  and  the 
eyeballs.  The  jaws  are  often  set,  and  sometimes  an  excess  of  saliva,  or  even 
foam,  gathers  about  the  mouth.  In  the  profoundest  cases  there  is  complete 
ansesthesia  of  both  the  common  and  the  special  senses,  so  that  neither  pinching 
nor  cutting,  neither  cold  nor  heat  applied  to  the  skin,  elicits  response.  The 
pupils  are  usually  dilated,  and  often  respond  to  a  powerful  light,  which,  how- 
ev.er,  calls  forth  no  other  signs  of  life.  Sometimes  the  patient  can  be  readily 
fed  by  means  of  a  spoon,  but  generally  in  severe  cases  it  is  necessary  to  use  the 
oesophageal  tube.  Usually  digestion  is  good,  but  the  stools  are  at  long  inter- 
vals and  scanty.  The  urine  is  in  most  cases  scantily  excreted  and  is  passed 
involuntarily.  Considering  the  small  amount  of  nourishment  taken,  the  bod- 
ily nutrition  is  often  surprisingly  maintained,  but  in  prolonged  cases  there 
comes,  sooner  or  later,  great  emaciation.  The  bodily  temperature  may  in  the 
earlier  parts  of  the  attack  be  somewhat  elevated,  but  ordinarily  it  is  distinctly 
subnormal.  The  awaking  is  usually,  but  not  always,  sudden.  During  the 
course  of  such  a  lethargy  the  subject  may  pass  into  a  condition  wdiich  has  been 
mistaken  for  death.  The  bodily  temperature  falls,  the  respiration  becomes  so 
passive  that  no  movement  of  the  thorax  or  abdomen  is  percei)tible,  and,  unless 
a  feather  or  other  light  object  be  held  over  the  mouth,  breathing  may  seem  to 
have  ceased.  The  beats  of  the  heart  diminish  in  frequency  and  in  force,  so 
that  they  become  imperceptible  even  upon  auscultation.  The  fiice  takes  on  the 
waxy  whiteness  of  a  corpse.  The  muscular  system  is  in  complete  relaxation, 
the  dilated  pupil  no  longer  reacts  to  light,  and  even  the  cornea  is  filmy  as  in  a 
corpse.  This  death-like  condition  may  last  for  only  a  few  hours,  or  may  con- 
tinue during  from  one  to  several  days,  after  which,  little  by  little,  respiration 
and  circulation  are  re-established.  After  such  a  crisis  the  subject  may  awake 
immediately  or  pass  into  a  new  sleep. 

Catalepsy  is  a  form  of  hysterical  lethargy  characterized  by  the  peculiar 
condition  of  the  muscles,  owing  to  which  the  body  or  the  limbs  remain  for  an 
indefinite  time  in  any  position   in   which  they  are  placed.     It  may  come  on 


HYSTERIA.  599 

gradually  or  abruptly  as  the  result  of  a  powerful  emotion,  but  usually  develops 
during  a  lethargy,  the  paroxysms  being  of  irregular  duration  and  sometimes 
continually  recurring.  The  facial  expression  may  be  that  of  apathy  ;  in  some 
cases  it  is  that  of  devotion,  of  rage,  or  of  whatever  passion  the  subject  was  in 
at  the  time  of  the  fixation  of  the  muscles.  The  eyes  are  wide  open,  with  quiet 
lids.  The  body  is  motionless  in  the  posture  in  which  it  has  been  placed  or  in 
which  it  has  settled  during  the  arrest  of  active  motion.  There  is  no  power  of 
voluntary  movement,  but  the  limbs  are  not  rigid  or  contracted.  When  taken 
hold  of  they  bend  with  the  plasticity  of  wax.  In  any  position  in  which  the 
body  or  limbs  are  placed  they  i-emain  for  a  long  time.  Bcrger  (quoted  by 
Barth)  is  said  to  have  seen  the  most  bizarre  and  difficult  attitudes  steadilv 
maintained  for  seven  consecutive  hours  by  a  young  cataleptic  woman  who  was 
constantly  under  observation.  During  the  whole  of  the  cataleptic  state  there 
is  complete  anaesthesia  of  both  the  common  and  the  special  senses,  so  that  the 
most  violent  irritations  of  the  skin  produce  no  reaction.  Respiration  is  reg- 
ular, the  pulse  maintains  its  normal  rhythm  and  rate,  and  the  general  bodily 
functions  appear  to  go  on  unaffected. 

If  the  patient  be  regularly  ied  with  liquid  food  at  intervals,  hysterical  sleep 
may  last  uninterru])tedly  for  many  wrecks,  months,  or  even  years.  Sometimes 
the  patient  will  occasionally  wake  to  take  food. 

Ili/derical  Paralysis  may  simulate  almost  any  form  of  organic  palsy. 
Paralysis  of  the  whole  body  is  exceedingly  rare,  but  such  cases  are  reported. 
The  face  also  is  not  often  affected,  and  the  ocular  nuiscles  usually  escape. 
Nevertheless,  hysterical  strabismus  and  liysterical  inecpiality  of  the  ])npil  are 
occasionally  seen.  Hysterical  monoplegia  is  not  frequent;  hysterical  hemi- 
plegia is  very  common,  but  the  most  frequent  variety  is  hysterical  ]iaraplegia. 

Hysterical  Paraplegia  may  coexist  with  nniscular  relaxations  or  contrac- 
tions (see  page  596),  with  normal,  abolished,  or  exaggerated  knee-jerk,  and 
even  with  ankle-clonus.  The  sensory  nervous  system  may  or  may  not  par- 
ticipate in  the  disturbance — in  some  cases  there  is  excessive  hyperresthcsia,  with 
or  without  pain  ;  more  frequently  the  sensibility  is  lessened  or  abolished  ;  usu- 
ally the  muscular  sense  is  at  least  as  much  affected  as  is  cutaneous  sensibility. 
Sometimes  electro-sensibility  is  abolished.  If  true  girdle  sensation  ever  occur 
in  hysterical  paraplegia,  it  must  be  very  rare :  the  real,  not  suggested,  pres- 
ence of  such  a  sensation  is  almost  pathognomonic  of  organic  disease. 

In  Hysterical  Hemiplegia  one  extremity  is  in  most  cases  distinctly  more 
affected  than  the  other,  and  the  face  is  very  rarely  imi)licatcd  ;  the  presence  of 
facial  palsy  tells  strongly  against  the  probability  of  an  hysterical  origin.  The 
palsy  is  rarely  complete,  so  that  a  patient  unable  to  walk  or  even  stand  may 
be  able  to  raise  the  foot  when  in  bed.  Tiiere  is  usually,  but  not  always,  a 
more  or  less  pronounced  loss  of  sensation  in  the  paralyzed  part,  ami  (he  coex- 
istence of  a  hemianesthesia  with  hemiplegia  should  always  arouse  suspicion. 

Ifysterical  iJisturhances  of  Sensation  may  take  the  form  of  hypera>sthesia, 
anffisthe.sia,  or  pancsthcsia.  Hysterical  Hypenrsthcsia  may  follow  the  regional 
distribution  ccjnimoulv  seen   in  an;e.sLlusia,  but  is  usually  irregular  in   its  dis- 


600  FUNCTIONAL    NERVOUS  DISEASES. 

ti'ibution  and  often  interrupts  anaesthetic  tracts.  Certain  local  hysterical 
hvpersesthcsias  are  so  important  as  to  require  special  notice.  Hypersesthesia 
in  the  o-enitals  is  very  common  in  the  female,  is  usually  associated  with  loss  of 
sexual  desire,  and  commonly  lies  at  the  foundation  of  the  condition  known  as 
vaginismus,  in  which  any  attempts  at  coitus  produce  an  overpowering  vaginal 
spasm.  Hypersesthesia  of  the  mamma  is  usually  attended  with  swelling, 
excessive  tenderness,  and  violent  pain,  sometimes  shooting  down  the  arm. 
(See  Diagnosis.)  Hypersesthesia  with  vaso-motor  swelling,  and  even  true  exu- 
dation, may  in  almost  any  of  the  larger  joints  mimic  organic  disease.     (See 

Diagnosis.) 

Hypersesthesia  of  the  special  senses  is  a  very  common  hysterical  symptom  : 
especially  is  photophobia  both  frequent  and  severe.  Indeed,  photophobia 
without  distinct  disease  of  the  eye  is  almost  always  hysterical.  A  special-sense 
hyperesthesia  may  show  itself  simply  in  the  pain  caused  by  the  natural  stimulus 
of  the  affected  organ,  but  may  also  take  the  form  of  a  true  functional  exalta- 
tion, so  that  vision  or  hearing  becomes  much  more  acute  than  normal.  In  my 
experience  this  form  of  hypersesthesia  has  been  especially  frequent  in  regard 
to  hearing.  Not  rarely,  hysterical  women  will  understand  and  repeat  conver- 
sations spoken  in  apartments  at  such  distance  from  their  own  that  the  ordinary 
ear  catches  no  sound. 

Hysterical  Ancesthesia  may  exist  in  any  portion  of  the  body,  but  in  the 
majority  of  cases  it  takes  the  form  of  heraiansesthesia.  This  hemiansesthesia 
is  apt  to  be  interrupted  by  spots  of  hyperaesthesia,  especially  in  the  region  of 
the  groin  or  in  the  ovary  itself,  or  in  the  dorsal  and  lumbar  regions  posteriorly, 
or  in  the  limited  vertical  space  from  one  to  two  inches  wide  stretching  from 
the  lower  cervical  region  upward.  The  hypersesthesia  in  these  cases  may  be 
superficial  or  may  be  only  elicited  by  deep  pressure. 

In  neurasthenic  women,  especially  young  women,  hypersesthesia  or  super- 
ficial tenderness  all  over  the  vertebral  column  is  so  common,  and  exists  in  so 
many  cases  without  very  pronounced  hysterical  symptoms,  as  to  be  commonly 
spoken  of  as  a  disease,  the  so-called  Spinal  Irritation  or  Spinal  Ancemia. 
There  is  not,  however,  any  reasonable  foundation  for  the  theory  that  the  con- 
dition depends  upon  ansemia  or  any  other  recognizable  lesion  of  the  s})inal 
cord,  or  that  it  is  entitled  to  a  distinct  place  in  nosology.  The  cases  shade  from 
the  slightest  form  of  vertebral  tenderness  to  major  hysteria.' 

Hysterical  ansesthesia  may  be  limited  to  one  organ,  like  the  cornea  of  the 
eye,  may  involve  the  mucous  membranes  as  well  as  skin  and  deeper  tissues, 
and  may  be  complete  or  incomplete.  Thermo-ansesthesia  is  common,  whilst 
analgesia,  existing  by  itself,  is  almost  invariably  hysterical.  Hysterical 
ansesthesia  is  usually  accompanied  by  the  so-called  ischoemia.  In  this  con- 
dition tlie  surface  is  pale  and  the  needle  prick  or  even  an  extensive  superficial 

■  The  treatment  of  spinal  irritation  is  that  of  neurasthenia  and  a  mild  hysteria.  It  is  true 
that  sometimes  henefit  is  obtained  by  local  ai)[)liances  of  belladonna  plasters,  or  even  by  mild 
blistering,  but  it  is  impossible  to  determine  how  far  this  treatment  acts  through  expectant  atten- 
tion and  how  far  it  has  any  direct  influence. 


HYSTERIA.  601 

incised  wound  does  not  bleed.  Anaesthetic  ischaemia  appears  to  be  specially 
pronounced  in  the  violent  epidemic  forms  of  hysteria,  such  as  occurred  in  the 
Convuhionnaires  of  the  Middle  Ages ;  hence  the  miracle  that  superficial 
AVdunds  were  not  followed  by  loss  of  blood. 

In  hysterical  hemiansesthesia  the  special  senses  are  usually  affected,  and 
there  may  be  loss  of  hearing,  smell,  taste,  and  vision.  Usually,  however,  the 
special  senses  are  not  completely  set  aside.  Amblyopia  is  conmionly  shown  by 
a  concentric  narrowing  of  the  field  of  vision  and  a  peculiar  loss  of  color  sense, 
the  achromatopsia  of  Galezowski.  In  some  cases  the  power  of  seeing  the 
colors  is  entirely  lost,  so  that  all  objects  appear  of  a  uniform  sepia  tint.  When 
the  achromatopsia  is  not  complete  the  colors  disappear  in  a  constant  order. 
The  first  color  that  an  hysterical  person  ceases  to  see  is  violet :  usually,  but 
not  always,  blue  is  lost  before  red,  the  intermediate  tints  fading  out  in  regular 
succession.' 

The  digestive,  eircidatory ,  and  respiratory  systems  are  frequently  deranged 
in  hysteria. 

Cardiac  irritability  is  very  common,  the  slightest  emotional  or  other  excite- 
ment producing  violent  tumultuous  palpitation,  which  in  some  cases  is  accom- 
panied by  great  discomfort,  and  even  irregularity  and  interruption  of  the 
heart's  action,  with  more  or  less  cardiac  distress.  In  some  cases  a  violent 
pain  in  the  cardiac  region,  shooting  down  the  arm,  closely  simulates  angina 
pectoris,  the  simulation  being  rendered  more  complete  by  the  excessive  rapidity 
and  smallness  of  the  pulse.  I  have  seen  this  pseudo-angina  pectoris  more 
frequently  in  young  men  than  in  other  hysterics,  and  when  in  such  cases  the 
general  signs  of  hysteria  are  not  pronounced  a  false  diagnosis  may  readily 
be  made.  ''  Flushings,"  with  a  sensation  of  intense  heat  and  a  sudden  out- 
burst  of  perspiration,  occur  in  hysteria,  but  are  especially  connected  with  the 
climacteric  period  in  women.  Unilateral  flushing,  local  cedematous  swellings, 
and  similar  phenomena,  though  rare  in  hysteria,  demonstrate  the  possibility 
of  local  vaso-motor  disturbance. 

Possibly  as  the  residt  of  vaso-motor  relaxation  are  the  luemorrhages  from 
the  nose  or  stomach,  which  are  specially  j)ronc  to  be  severe  when  menstruation 
is  suppressed.  Care  is  often  necessary  to  avoid  mistaking  for  a  true  haemop- 
tysis the  bleeding  which  a  designing  woman  produces  by  sucking  or  otherwise 
irritating  the  gums. 

'  It  seems  necessary  to  advert  to  the  so-called  inetallo-tlierapy  first  originated  liy  Or.  Ilurk, 
who  fonnd  tliat  different  hysterical  individuals  have  such  relations  with  difloront  nietaliic  sub- 
stances that  wl)cn  a  small  disk  of  tlu;  apijropriato  snhstanre  is  hound  over  the  ana-stlietic  jiart  a 
sensation  of  warmth,  with  slij,'lit  ri'iiiicss  and  disappcarcncc  of  tlie  ischn'mia  and  ana'sthesia, 
follows.  In  some  cfises  not  only  is  the  sensibility  of  tlu;  skin  restored,  Init  if  tlic  i)late  Ite  in  the 
neifchborhood  of  the  orbit,  vision  returns.  Also,  often  the  so-called  "  transfer "  phenonicna 
ayipear— ?.  r.  loss  of  sensibility  and  ischiiniia  develop  ui)on  the  uni)araly7.ed  side  in  the  jiosition 
corresponding  to  the  seat  of  tbc  metallic  application.  Powerful  maf;nets  have  been  found  to 
have  a  similar  indnence  to  the  metal,  and  even  disks  of  wood  have  been  succcs-sfully  employed. 
It  is  very  difliciilt  in  this  country  to  obtain  transfer  phenomena,  and  it  seems  almost  certain  that 
they  are  the  result  of  expectant  attention. 


602  FUNCTIONAL    NERVOUS   DISEASES. 

■m 

Tlie  bodily  temperature  rarely  departs  from  the  norm  in  hysteria,  and  in 
simulated  acute  disease  advantage  can  often  be  taken  of  the  fact  for  diagnostic 
purposes ;  nevertheless,  hysterical  fever  does  occur.  According  to  M.  Briand 
and  other  French  writers,  there  are  three  types  of  it — in  the  first  form  the 
paroxysms  are  irregular,  of  long  duration,  accompanied  by  various  nervous 
disturbances ;  in  the  second  variety  the  fever  continues  from  one  to  four  weeks 
and  is  accompanied  by  disturbance  of  the  nutrition,  in  some  cases  the  whole 
course  of  the  affection  closely  mimicking  a  typhoid  fever;  in  the  third  form 
the  paroxysms  of  fever  occur  with  more  or  less  regularity,  so  as  to  give  the 
appearance  of  a  true  intermittent  fever.  Exaggerated  temperatures,  120°  or 
130°  F.,  have  been  recorded  from  time  to  time  as  occurring  in  hysterical 
patients.  Most,  if  not  all,  of  these  high  records  have  been  due  to  skilful 
manipulation  of  the  thermometer  by  a  designing  patient,  but  there  is  reason 
for  suspecting  that  extraordinary  local  elevations  of  temperature  happen  in 
hysteria. 

Hysterical  disturbances  of  respiration  are  common.  Intensely  rapid  breath- 
ing, 50  to  150  per  minute,  the  so-called  "hysterical  dysp^ioea,"  may  occur 
without  alteration  of  the  pulse-rate,  and  may  be  associated  with  thoracic 
symptoms  misleading  to  the  inexperienced  practitioner.  Hoarse,  croaking, 
laryngeal  cough,  seemingly  almost  luicontrollable,  is  a  frequent  hysteric  phe- 
nomenon, as  is  also  aphonia  from  laryngeal  palsy.  Violent  paroxysms  of 
acute  dyspnoea  may  occur  from  hysterical  laryngeal  spasm,  simulating  attacks 
of  true  laryngismus  stridulus. 

Secretion  is  often  affected  in  hysteria.  Excessive  sweating  is  very  com- 
mon, and  a  profuse  sweating  may  be  accompanied  with  a  sufficient  haemor- 
rhage to  color  it  deep  rose-red  (hcematidrosis).  One  of  the  most  characteristic 
symptoms  of  an  hysterical  paroxysm  is  the  free  discharge  of  limpid,  light- 
colored  urine,  evidently  due  to  vaso-motor  and  secretory  disturbances  in  the 
kidneys.  More  serious  is  the  partial  or  even  complete  suppression  of  urine 
{anuria),  which  may  for  many  months  almost  completely  prevent  the  excre- 
tion of  the  urinary  solids  through  the  normal  channel.  Under  these  circum- 
stances the  sweat,  the  vomit,  and  other  seca^etions  become  loaded  with  urea. 

Disturbances  of  digestion  are  almost  universal  in  hysteria.  Constipation 
is  very  common  and  not  rarely  very  obstinate.  Diarrhoea  is  more  rare. 
Flatulence,  gastric  and  intestinal,  is  sometimes  accompanied  by  extraordinary 
distension  of  the  bowels,  and  occasionally  by  irregular  spasmodic  contraction 
of  the  abdominal  muscles,  producing  strange  internal  noises.  Hysterical 
oesophageal  spasm  may  for  a  while  prevent  swallowing,  whilst  hysterical 
vomiting  is  one  of  the  most  frequent  of  symptoms.  This  vomiting  may  be 
excessive  and  continue  for  days  and  weeks,  so  severely  and  so  persistently  that 
the  patient  seems  to  retain  no  food  whatever,  the  appetite  being  replaced  by 
an  absolute  loathing  for  food.  Such  cases  constitute  the  so-called  "fasting 
girls"  who  from  time  to  time  become  the  centre  of  attention  and  wonder  on 
the  part  of  whole  communities.  The  ability  of  the  hysteric  to  live  upon  the 
smallest  quantity  of  food  is  often  extraordinary,  but  there  can  be  no  doubt  that 


HYSTERIA.  603 

in  the  notorious  instances  of  alleged  fasting  deception  has  played  an  important 
role.  The  vomiting  may  be  accompanied  by  reversion  of  intestinal  peristalsis, 
resulting  in  the  discharge  of  i'seeal  matter  from  the  mouth,  and  cases  are  on 
record  in  which  rectal  injections  were  in  a  short  lime  thrown  up  from  the 
stomach. 

Diagnosis. — The  diagnosis  of  major  or  minor  hysteria  occurring  in  gene- 
ral paroxysmal  form  requires  no  further  discussion.  The  recognition  of  the 
true  nature  of  an  hysterical  paralysis  may  be  very  difficult. 

The  presence  of  other  distinct  symptoms  of  hysteria,  either  in  the  past  or 
in  the  present,  is  of  importance.  Nevertheless,  a  violently  hysterical  person 
may  be  attacked  by  organic  palsy,  and  I  have  also  seen  hysterical  paraplegia 
occurring  without  other  symj)toms  of  hysteria  and  Avithout  an  hysterical  his- 
tory that  could  be  made  out.  The  hysterical  palsy  is  apt  to  be  transient  and 
shifting  in  its  character,  to  go  and  come  suddenly,  and  not  to  conform  in 
its  minor  phenomena  with  the  sequences  and  coincidences  of  organic  palsy. 
Again,  the  hysterical  palsy  is  often  accompanied  by  symptoms  that  do  not 
occur  in  the  organic  paralysis  which  is  simulated.  Thus  an  hysterical  hemi- 
plegia or  a  monoplegia  may  be  attended  with  ]iaralysis  of  the  bladder,  of  the 
intestines,  or  of  the  rectum,  although  paralysis  of  the  visceral  walls  is  very 
rarely  if  ever  present  in  organic  hemiplegia  or  local  paralysis;  or  an  hyster- 
ical hemianse-sthesia  is  not  properly  situated  in  its  relations  M'ith  the  coexisting 
motor  palsy  ;  or  electro-sensil)ility  is  lost  when  general  sensibility  is  preserved, 
etc.  etc.  An  atypical  paralysis  should  always  be  viewed  with  suspicion — in 
women  it  is  usually  hysterical ;  in  men  it  is  usually  syphilitic,  but  may  be 
hysterical. 

An  hysterical  monoplegia  is  not  infrequently  attributed  to  an  injury.  If 
contractures  conae  on  immediately  after  a  real  or  an  alleged  injury,  the  paraly- 
sis is  probably  hysterical ;  but  complete  relaxation  may  exist  in  an  hysterical 
monoplegia.  When  after  a  traumatism  the  paralysis  and  the  relaxation  are 
complete  and  there  is  no  wasting  of  the  muscles,  the  affection  is  usually  hys- 
terical, since  in  all  cases  of  total  or  nearly  total  loss  of  power  from  injuries  to 
a  nerve  the  muscles  rapidly  change.  Irregularities  in  the  anatomical  relations 
between  the  disturbances  of  sensibility  and  the  alterations  of  mobility  indi- 
cate an  hysterical  origin,  but  these  relations  may,  in  hysteria,  conform  to  the 
organic  type. 

In  consentaneous  organic  palsies  of  sensation  and  motion  sensation  almost 
always  improves  first — in  mimicking  hysterical  states  motion  u.sually  imjiroves 
before  sensation.  In  organic  hemiplegia  aphasia  is  frequent ;  in  hysterical  it 
is  v(!ry  unusual. 

Hysterical  affection  of  the  larger  joints  sometimes  so  closely  simulates 
chronic  inflammation  as  to  make  the  diagnosis  a  matter  of  some  dilhculty. 
The  presence  of  other  hysterical  symptoms  is  important,  and  usually  the  true 
nature  of  an  hysterical  joint  can  be  recognized  by  attentidii  to  the  following 
considerations:  first,  the  muscular  rigidity  or  contraction  can  be  overcome  by 
mildly  persistent  efforts  while  the  patient's  mind  is  diverted,  yields  n^adily 


604  FUNCTIONAL    NERVOUS   DISEASES. 

during  natural  sleep,  and  disappears  during  slight  anaesthesia  or  even  under 
a  full  dose  of  chloral  or  opium ;  secondly,  there  is  no  rise  in  temperature  in 
the  joint,  although  the  part  looks  red  and  inflamed ;  thirdly,  the  reaction  of 
the  contracted  and  apparently  atrophied  muscles  to  the  faradic  current  is 
normal. 

The  knee  is  the  part  most  frequently  implicated,  but  mimetic  disease  of  the 
hip-joint  is  especially  misleading.  It  should  be  noticed  that  the  limp  varies 
from  day  to  day  as  the  patient's  attention  is  directed  to  or  diverted  from  the 
joint — that  it  is  exaggerated  by  fatigue  and  nervous  exhaustion,  and  hence 
is  usually  more  pronounced  in  the  evening  than  in  the  morning.  Moreover, 
in  the  onset  of  an  organic  disease  the  patient  usually  begins  to  limp  before 
he  complains  of  pain,  whilst  in  the  hysterical  disorder  pain  generally  appears 
first. 

Hysterical  lateral  curvature  is  especially  prone  to  deceive  practitioners, 
owing  to  the  fact  that  true  lateral  curvature  is  very  frequent  in  neurasthenic 
women.  The  hysterical  curvature,  being  the  outcome  of  spasm,  disappears 
during  ansesthesia ;  the  organic  lateral  curvature  remains  unchanged  by  the 
anaesthetic. 

The  nature  of  the  hysterical  breast  is  to  be  recognized  by  the  excessive 
superficial  tenderness,  so  that  merely  brushing  or  handling  the  breast  causes 
as  much  pain  as  hard  pressure;  by  the  diffusiveness  of  the  swelling;  by  the 
constant  variation  in  size  and  in  hardness  :  and  by  the  recurrence  of  the  symp- 
toms at  the  menstrual  period,  at  the  approach  of  stormy  weather,  or  after 
general  fatigue.  Not  rarely  in  neurotic  girls,  and  sometimes  in  neurotic  boys, 
at  the  period  of  sexual  unfolding  one  breast  will  suddenly  become  hot,  exceed- 
ingly painful  and  tender,  and  perhaps  secrete  a  few  drops  of  sero-lacteal  fluid. 

The  so-called  phantom  tumor  of  hysterical  women  is  a  localized  swelling  in 
the  abdomen,  probably  the  result  of  local  muscular  spasm.  The  sensation 
imparted  to  the  fingers  may  be  exactly  that  of  a  hard  tumor.  Usually  the 
presence  of  percussion  clearness  renders  the  diagnosis  of  the  phantom  tumor 
easy,  but  in  obese  women  this  sign  may  fail.  The  true  nature  of  the  phantom 
tumor  is  always  revealed  by  its  disappearance  during  ansesthesia. 

Great  care  is  sometimes  necessary  to  prevent  mistakes  when  organic  nervous 
disease  develops  in  nervous  women  suffering  from  hysteria.  Among  the  most 
difficult  cases  that  I  myself  have  ever  met  with  are  those  in  which  inherited 
syphilis  lias  just  revealed  itself  after  puberty  in  an  hysterical  girl.  Basal 
meningitis,  poliomyelitis,  myelitis,  or  any  organic  disease  may  develop  in  an 
hysterical  person,  and  unless  cases  be  thoroughly  examined  grave  errors  will 
be  made.  I  have  seen  the  diagnosis  of  major  hysteria  persisted  in  by  good 
medical  practitioners  up  to  within  a  few  hours  of  the  death  of  a  patient,  when 
an  examination  of  the  urine  would  have  demonstrated  the  ursemic  nature  of 
the  disease.  Usually,  watchfulness  will  result  in  the  detection  of  choked  disk, 
trophic  change,  or  other  unmistakably  organic  symptom. 

It  is  usually  easy  to  recognize  the  nature  of  an  hysterical  ansesthesia 
through  the  existence  in  the  past  or  present  of  other  hysterical  manifestations, 


HYSTEBIA.  605 

and  especially  by  the  fact  that  frequently  when  motor  and  sensory  paralyses 
coexist,  they  do  not  conform  in  relative  position  to  the  organic  type  ;  further, 
the  organic  anesthesia  is  fixed  and  does  not  vary  from  time  to  time  in  its  lim- 
its, as  does  the  hysterical  anaesthesia  ;  and  the  organic  anesthesia  is  not  inter- 
rupted by  islets  of  normal  sensation  or  of  hyperaesthesia,  as  is  the  hysterical 
disorder. 

The  diagnosis  of  hysterical  blindness  can  often  readily  be  made  by  noting 
the  absence  of  the  causes  of  organic  blindness  and  the  presence  of  hysterical 
manifestations,  with  the  conformity  of  the  amblyopia  to  the  hysterical  charac- 
teristics already  given.  (See  page  594.)  A  simulated  monocular  blindness  can 
usually  be  detected  by  means  of  the  Graefe  prism  test :  if  a  jirism  held  before 
the  eye  in  which  sight  is  admitted  cause  double  vision,  or  if,  when  its  axis  is 
held  horizontally,  a  corrective  squint  develop,  vision  exists  in  both  eyes. 
Another  equally  certain  test  is  to  let  the  patient  read  with  both  eyes  at  sixteen 
or  twenty  inches,  and  slip  a  glass  of  high  focus  in  front  of  the  eye  alleged  to 
be  sound.  If  the  reading  continue  under  these  circumstances,  the  amaurosis  is 
feigned.  L.  Miiller's  test  for  mimetic  deafness  in  one  ear  is  to  have  different 
words  spoken  simultaneously  in  a  low  voice  in  two  tubes,  each  of  which  is  con- 
nected with  one  ear  of  the  patient.  If  the  apparent  deafness  be  real,  the  jiatient 
will  only  repeat  that  which  is  spoken  into  the  healthy  ear;  if  there  be  simula- 
tion, confusion  and  repetition  of  the  words  spoken  into  the  alleged  deaf  ear 
result.  In  any  case  of  simulated  paralysis  of  special  sense  betrayal  will  often 
occur  during  the  semi-conscious  stages  of  artificial  anesthesia. 

Prognosis. — Death  from  hysteria  is  almost  infinitely  rare,  although  Sir 
AVilliam  Gull  has  described  under  the  name  of  anorexia  nervosa  vel  hysteria  a 
condition  with  great  emaciation,  feeble  pulse,  fading  respiration,  and  low  tem- 
perature in  young  patients,  ending  sometimes  in  death.  It  is  hardly  probable 
that  these  cases  were  purely  hysterical.  Proper  forced  feeding  will  almost 
invariably  prevent  a  fatal  termination  in  hysterical  patients  who  refuse  food. 

When  the  hysterical  temperament  is  once  thoroughly  developed,  it  is  rarely 
if  ever  set  aside  completely,  though  it  may  be  held  in  abeyance.  The  chances 
of  complete  recovery  are  therefore  much  smaller  in  those  cases  in  which  by 
original  inheritance  or  by  faulty  education  the  person  has  become  an  ingrained 
hysteric  than  in  those  cases  in  which  by  transitory  emotional  pressure,  exces- 
sive mental  and  emotional  labor,  or  by  other  active  cause  a  previously  and 
iniieritedly  feeble  nervous  system  has  been  merely  for  the  time  being  thrown 
off  its  balance. 

Patholog'y. — Hysteria  is  based  upon  no  anatomical  peculiarity  of  the  ner- 
vous system  sufficiently  gross  U)  be  recognized  by  any  test  that  we  are  at  jircs- 
cnt  capaijle  of  apj)lying.  Tiicorics  almost  imunnerable  have  from  time  t(» 
time  been  suggested  t«  exj)lain  the  phenomena,  but  in  accordance  with  the 
general  rule  followed  throughout  this  work  no  discussion  of  these  theories  Mill 
be  hero  entered  upon.  All  that  we  know  is  that  hysteria  is  a  neurosis — /.  c.  a 
peculiar  nervous  state  which  may  be  the  result  of  inhci-itancc  or  of  moic  tem- 
porary causes. 


606  FUNCTIONAL    NERVOUS   DISEASES. 

Treatment. — For  the  purposes  of  discussion  the  treatment  of  hysteria 
naturally  divides  itself  into  preventive  and  curative. 

The  preventive  treatment  of  hysteria  consists  in  the  proper  education  of  the 
young,  it  being  possible  to  largely  overcome  the  results  of  inheritance  if  the 
attempt  be  begun  early  enough.  In  a  volume  like  this  there  is  not  space  for 
the  consideration  of  the  details  of  this  subject,  but  certain  general  principles 
which  ought  to  guide  all  efforts  can  readily  be  stated.  The  attempt  should  be 
— first,  to  increase  the  robustness  of  the  whole  person,  and  especially  of  the 
nervous  system  ;  second,  to  reduce  excessive  sensitiveness  by  accustoming  the 
nervous  system  to  moderate  exposure  and  hardships  ;  third,  to  develop  in  the 
child  the  habit  of  obedience  (first  to  those  who  are  above  him,  and  afterward 
to  his  own  personality,  led  by  a  sense  of  right  and  wrong  ;  in  other  words,  to 
teach  the  young  child  the  habit  of  subjection  to  control  from  witliout,  in  order 
that  the  power  of  self-control  from  within  may  later  be  developed)  ;  fourth,  to 
bring  about  so  much  of  intellectual  development  as  shall  give  to  the  patient 
abundance  of  interest  outside  of  herself  and  her  immediate  surroundings,  and 
shall  form  a  basis  for  character ;  fifth,  to  inculcate  unselfishness  and  to  develop 
other  traits  of  character,  such  as  are  recognized  as  worthv  of  imitation  through- 
out  the  world.  The  when,  the  where,  and  the  hoAV  these  things  shall  be 
done  depend  upon  the  circumstances  of  the  individual  child.  Country  life  is 
usually  preferable  to  city  life ;  a  moderate  living  to  the  home  of  luxury  ;  home 
training  to  training  in  boarding-schools  or  other  institutions ;  plain  food  to 
high  living. 

But  the  environment  of  the  individual  patient  may  change  these  things. 
Thus  if  the  mother  in  the  home  be  weak  and  hysterical  herself,  it  is  essential 
that  some  one  else  guide  the  young  life.  Again,  if  it  be  impossible  for  the 
child  to  be  reared  in  the  country  without  its  leaving  a  home  where  all  the 
influences  trend  toward  good,  it  may  be  better  to  sacrifice  the  country  life  and 
to  attempt  to  gain  its  advantages  by  gymnastics  and  athletic  outdoor  sports. 

In  the  treatment  of  developed  hysteria  it  is  essential  to  remember  that  in 
the  majority  of  cases  the  hysterical  person  is  a  neurasthenic,  and  that  the  basal 
treatment  in  most  cases  must  therefore  be  that  of  neurasthenia.  The  rigidity 
with  which  this  treatment  must  be  enforced  depends  upon  the  needs  of  the 
individual  case,  but  the  removal  from  home,  the  putting  to  bed,  the  whole 
course  of  the  so-called  rest-cure  by  means  of  the  isolation  it  requires  affords 
opportunity  for  that  domination  and  control  by  the  physician  and  nurse  which 
are  so  necessary  in  the  treatment  of  hysteria. 

The  success  of  the  moral  treatment  of  the  hysteric  depends  upon  the  tact 
of  the  physician  and  of  the  nurse;  and,  as  the  latter  functionary  is  in  contin- 
ual contact  with  the  patient,  she  is  very  important.  Unless  the  nurse  be  proper- 
ly selected  with  view  to  the  work  at  hand,  all  efforts  at  cure  must  fail.  The 
object  of  the  moral  management  is  to  develop,  first,  a  willingness  to  be  unself- 
ish ;  second,  the  habit  of  self-control.  In  some  intelligent  hysterics  a  careful, 
skilful  putting  before  them  of  their  own  nature,  of  its  difficulties,  dangers,  and 
possibilities,  has  a  most  happy  effect,  but  great  care  is  necessary  in  the  selection 


HYSTERIA.  607 

of  the  individual  to  be  managed  in  this  way.  Very  frequently  such  treatment 
will  do  harm.  In  more  severe  cases  absolute  control  from  outside  is  necessary : 
the  habit  of  obedience  or  submission,  once  formed,  becomes  the  basis  of  advance 
of  character.  The  first  thing  to  do  is  to  let  the  patient  see  that  complaints  will 
not  bring  sympathy,  but  will  rather  excite  disgust  in  the  mind  of  the  hearer 
and  disregard  for  the  patient.  The  next  point  is  to  make  the  hysterical  attacks 
as  disagreeai)le  as  possible  to  the  patient.  This  is  not  simply  because  the  attacks 
may  be  simulated  or  brought  on  by  a  direct  eifort  of  the  will,  but  that  a  motive 
may  be  furnished  the  patient  which  will  aid  the  will  in  preventing  an  attack  of 
hvsteria.  The  hypodermic  injection  of  apom()rj)hine  will  usually  cause  vomit- 
ing and  arrest  of  an  hysterical  paroxysm,  and  where  the  attacks  recur  at  short 
intervals  the  apomorphine  treatment  is  often  advantageous.  When  a  hosjiital 
resident  physician  I  found  that  in  women  who  were  brought  in  from  the  street 
by  policemen  the  production  of  a  ])air  of  shears  and  the  commencing  of  cut- 
ting the  liair  off,  preparatory,  as  was  loudly  stated  to  the  policeman  standing 
by,  to  the  putting  of  a  blister  on  the  scalp,  would  have  a  more  quieting  influ- 
ence upon  a  furious  hysterical  paroxysm  than  would  the  efforts  of  several 
strong  men.  Even  though  the  patient  seemed  unconscious,  invariably  the 
convulsive  movements  and  the  delirium  ceased.  In  an  epidemic  of  hysteria 
which  occurred  in  one  of  our  Philadelphia  charity  schools  two  most  obstinate 
cases  resisted  the  cold  douche,  blisters,  and  even  the  hot  iron  :  no  procedure  had 
the  slightest  effect  in  preventing  the  continual  recurrence  of  beast  mimicry  and 
other  hysterical  paroxysms.  The  two  children  were  finally  kept  without  food 
for  three-quarters  of  a  day,  and  then  fed  as  much  as  they  would  take.  To  one 
of  them,  in  the  presence  of  the  other,  was  then  given  ether,  as  slowly  and  as 
disagreeably  as  possible,  so  as  to  provoke  screaming,  fighting,  and  excessive 
vomiting.  This  put  an  end  to  the  symptoms  in  the  one  that  suffered  and  the 
one  that  witnessed  the  suffering. 

The  effect  of  a  motive  in  hysteria  is  sometimes  most  extraordinary.  The 
well-known  sudden  restorations  of  power  to  limbs  that  have  been  palsied  for 
years,  or  to  patients  that  have  been  bedridden  for  decades,  through  strong 
religious  excitement  and  faith,  are  supplemented  by  cases  in  \\\m'h.  the  emotion 
has  been  fear  or  rage.  I  have  known  a  woman  who  had  been  motionless  in  bed 
for  many  years,  enraged  by  the  treatment  of  her  |)hysician,  leap  from  the  bed 
and  tear  the  clothes  off  his  back  before  she  could  be  restrained.  These  cases 
illustrate,  however,  rather  the  result  of  emotional  excitement  than  of  a  motive. 
Not  so  an  instance  in  which  a  poor  but  very  beautiful  hysterical  girl,  engaged 
to  a  rich  man,  was  informed  by  the  latter  that  though  he  loved  her  he  could  not 
live  with  a  woman  who  vomited  continually,  and  that  the  marriage  would  have 
to  be  postponed  until  the  vomiting  ceased  ;  and  behold  !  how  soon  that  incoer- 
cible  vomitin<r  ceased!  In  this  case  the  patient  did  not  vomit  purposely,  but 
the  strongly  ex(;ited  will  finally  controlled  the  stomach. 

In  endeavoring  to  carry  on  the  moral  management  of  the  hysterical  patient 
it  is  essential  that  the  physician  do  not  intensify  the  sym|)toms  by  too  much 
attentifjti.     The   hysterical   woman  often   craves   for   medical   sympathy,  and 


608  FUNCTIONAL    NERVOUS   DISEASES. 

occasionally  luis  toward  tiie  doctor  distinctly  sexual  feelings,  so  that  caution  is 
sometimes  necessary  not  to  do  her  more  harm  than  good.  In  those  cases  in 
which  paralysis,  vomiting,  or  other  active  functional  derangement  exists  the 
patient  should  be  taught  that  constant  effort  will  often  overcome  the  evil. 

Hypnotism  is  sometimes  of  great  value  in  the  treatment  of  hysterical 
symptoms,  but  the  greatest  care  is  necessary  in  using  the  method,  as  the  atten- 
tion which  it  brings  to  the  patient  and  the  state  itself  may  do  grave  injury. 
I  have,  however,  seen  rapid  cures  by  it  of  hysterical  contractures  which  had 
resisted  all  other  treatment.  Hypnotism  is  especially  dangerous  when  the 
hysteria  is  deeply  seated  in  an  original  lack  in  the  nervous  system  :  in  acci- 
dental hysteria  it  may  be  used  more  freely.  I  do  not  believe  at  all  that  the 
cure  in  these  cases  is  due  to  any  suggestions  made  in  the  hypnotic  state :  the 
result  of  treatment  is  rather  the  outcome  of  a  mental  impression. 

The  same  may  be  said  of  mock  surgical  operations,  which  may  occasionally 
be  used  with  excellent  result,  but  which  are  of  course  especially  liable  to  abuse. 
Bread  pills  given  with  absolute  carefulness  as  to  detail  of  administration  some- 
times work  wonders.  Of  exactly  the  same  character  are  the  so-called  faith 
cures,  pilgrimages,  etc.  One  of  the  worst  cases  of  chronic  hysteria  I  ever 
knew,  who  has  been  much  in  the  newspapers  in  recent  times  as  having  been 
cured  by  a  pilgrimage  to  Our  I^ady  of  Lourdes,  was  the  subject  of  a  clinical 
lecture  by  myself,  published  ten  years  ago,  in  which  lecture  it  was  stated  that 
the  woman  would  probably  some  time  be  relieved,  but  not  by  the  doctors. 

Certain  drugs  belonging  to  the  so-called  class  "antispasmodics,"  notably 
asafoetida,  valerian,  musk,  and  camphor,  are  useful  remedies  in  the  treatment 
of  mild  hysteria,  since  they  often  abate  the  symptoms,  quiet  the  nerve-excite- 
ment of  the  patient,  and  never  do  harm.  The  bromides  have  more  influence 
than  any  one  of  these  remedies,  but  are  distinctly  more  capable  of  harm,  and 
should  only  be  allowed  at  the  discretion  of  the  physician.  Chloral,  morphine, 
and  other  narcotics  may  sometimes  be  used  with  advantage,  but  the  danger  of 
the  production  of  the  narcotic  habit  is  very  great,  and  neither  of  these  rem- 
edies nor  alcohol  should  under  any  circumstances  be  prescribed  to  the  patient 
with  knowledge  on  her  part  of  what  she  is  taking. 

Local  treatment  in  hysteria  is  always  accompanied  with  a  danger  of  in- 
creasing the  symptom  by  calling  attention  to  it ;  nevertheless,  in  many  cases 
it  is  necessary.  Pains  which  seem  agonizing  will  often  be  forgotten  in  a 
moment  under  some  pleasurable  excitement,  and  the  attempt  to  relieve  pain 
by  narcotics  always  endangers  the  formation  of  the  narcotic  habit.  The  head- 
aches of  hysteria  can  sometimes,  however,  be  much  benefited  by  the  use  of 
the  bromides  or  of  cannabis  indica. 

In  pseudo-hysterical  angina  it  is  probable  that  the  pain  itself  is  not  alto- 
gether purely  hysterical,  but  the  result  of  an  hysterical  spasm  or  loss  of  power 
in  some  portion  of  the  cardiac  apparatus.  Certainly  this  pain  is  often  relieved 
by  nitro-glycerin  or  nitrite  of  amyl,  and  the  paroxysms  prevented  by  the  per- 
sistent use  of  cardiac  tonics,  such  as  digitalis  and  caffeine.  Counter-irritation 
sometimes  will  relieve  the  pain  of  hyperaesthetic  ovaries,  and  occasionally  is 


VERTIGO.  G09 

of  value  against  the  tenderness  of  the  so-called  spinal  irritation.  Usually, 
however,  in  these  cases  the  application  of  a  belladonna  plaster  is  more  suc- 
cessful. In  severe  eases  of  pain  hypodermic  injections  of  water  sometimes 
have  a  marvellous  effect.  This  effect  of  such  injections  is  especially  pronounced 
in  hysterical  insomnia,  deep  sleep  being  frequently  produced  by  a  few  drops  of 
a  fluid  which  the  patient  believes  is  a  saturated  solution  of  morphine. 

In  the  treatment  of  painful  special-sense  hyperiesthcsia  it  is  essential  that 
the  patient  be  not  allowed  to  be  shut  up  in  dark  rooms  or  in  excessively  quiet 
apartments,  but  to  be  forced  to  endure  at  least  a  moderate  amount  of  the 
natural  stimulus  which  it  is  affirmed  causes  so  much  pain.  I  have  cured 
severe  hysterical  blindness  on  one  side  by  closing  the  sound  eye  hermetically 
with  sticking-plaster  and  putting  blisters,  one  after  the  other,  behind  the  ear 
and  on  the  temple  of  the  blind  side,  the  })atient  being  informed  that  the  fast- 
ening up  of  the  well  eye  and  the  blistering  would  be  kept  up  indefinitely 
until  siffht  returned  to  the  affected  oro;an. 

In  hysterical  paralysis  faradization  and  massage  are  often  of  great  service, 
provided  the  patient  be  impressed  with  the  belief  in  their  power  for  good. 
Hysterical  contractures  are  among  the  most  obstinate  of  symptoms  :  occasion- 
ally they  can  be  affected  by  static  or  faradic  electricity,  by  blistering,  or  by 
other  procedures  which  produce  a  distinct  moral  or  physical  perturbation.  I 
have  found  in  obstinate  cases  very  marked  benefit  from  the  subcutaneous 
section  of  the  tightened  tendons.  How  far  such  operations  do  good  directly, 
and  how  far  they  produce  their  effects  by  causing  a  mental  impression,  is 
uncertain.  As  already  stated,  hypnotism  is  of  special  value  in  this  form  of 
hysteria. 

Hysterical  retention  of  the  urine  requires  the  exercise  of  great  tact  in  its 
management.  On  the  one  hand,  the  long  distension  of  the  bladder  may  pro- 
duce organic  disease ;  and,  on  the  other  hand,  a  large  element  in  the  pro- 
duction of  the  retention  may  be  the  desire  of  the  woman  to  have  the  doc- 
tor draw  off"  her  urine.  The  catheter  should  always  be  passed  by  a  female 
nurse,  the  doctor  ])ositively  refusing  to  do  it. 

Hysterical  vomiting  is  to  be,  at  first  at  least,  totally  disregarded.  If,  how- 
ever, it  persist  and  become  severe  enough  to  attack  nutrition,  the  various 
antiemetics,  especially  cocaine,  may  be  tried,  but  artificial  feeding  should  soon 
be  resorted  .to.  Semi-liquid,  half-digested  food  should  be  given  by  means  of 
the  nasal  oesophageal  tube,  the  process  being  made  distinctly  disagreeable  for 
the  patient. 

Vertigo. 
Vertigo,  or  the  sensation  oC  moving  or  ol"  an  appearance  of  motion 
in  surrounding  objects  which  are  really  at  rest,  varies  ['nww  the  slightest 
swimminif  of  the  head  to  the  attacks  in  wliicli  the  victim  seems  invoKcd  in 
a  whirling  chaos  of  raotitju.  In  the  more  severe  attacks  the  ground  un(hi- 
lates  or  rises  or  sinks;  houses  move;  li ills,  trees,  and  rocks  slant  hitlier  and 
thither;  and   in  some  instances  llie  whole  landscajx'  inverts  itself  and  hangs 


610  FUNCTIONAL    NERVOUS   DISEASES. 


is- 


abovo  the  head,  threatening  ruin.     In  these  severe  cases  there  may  be  d 
(inct  perversion  of  special  senses.     The  term  vertiginous  status  is  aj)plied  to 
the  condition  in  which  paroxysms  of  vertigo  occur  in  rapid  succession. 

Vertigo  may  be  organic,  dependent  upon  organic  disease  of  the  nerve-cen- 
tres ;  cardiac,  due  to  disturbance  of  the  circulation  ;  epileptic,  the  outcome  of 
idiopathic  ej)ilepsy  ;  hysterical  or  neurasthenic,  including  cases  due  to  nervous 
exhaustion  ;  peripheral,  due  to  a  peripheral  irritation  ;  special  sense,  due  to 
derangement  of  the  special  senses  ;  toxcemic,  due  to  the  presence  in  the  blood  of 
some  poison  ;  essential,  including  cases  whose  pathology  is  at  present  unknown. 

Organic  Vertigo  may  arise  from  almost  any  form  of  brain  disease:  it  is 
exceedingly  common  in  the  invasion  of  multiple  cerebral  sclerosis,  and  may  be 
the  outcome  of  a  specific  or  of  a  true  locomotor  ataxia. 

Concerning  Epileptic  Vertigo  see  Epilepsy. 

Cardiac  Ver'tigo  is  usually  seen  in  fatty  degeneration  or  other  disease  of  the 
heart  accompanied  by  failing  power,  and  is  usually  to  be  recognized  by  the  fact 
that  it  is  produced  by  any  sudden  severe  exertion  or  is  accompanied  by  cardiac 
distress  or  by  fear.  Malde  montagne  (headache,  vertigo,  dyspnoea,  with  nausea 
and  vomiting),  produced  in  some  persons  by  the  rarefied  air  of  high  moun- 
tains, is  probably  a  cardiac  vertigo,  as  is  also  the  swimming  of  the  head  seen 
in  persons  of  advanced  age  with  atheromatous  arteries. 

Any  variety  of.  vertigo  may  be  closely  counterfeited  by  the  hysterical  affec- 
tion, which,  however,  frequently  takes  some  bizarre  atypical  form.  The  ver- 
tigo of  neurasthenia  is  rarely  severe,  and  is  especially  apt  to  be  provoked  by 
sudden  intense  peripheral  sense-irritation,  as  flashing  of  light,  etc. 

Among  the  peripheral  vertigoes  may  be  mentioned  the  affection  described 
by  Prof.  Charcot  under  the  name  of  laryngeal  vertigo,  in  which  laryngeal 
parsesthesise  with  spasmodic  cough  are  followed  by  a  brief  vertigo.  Some 
of  the  cases  reported  of  laryngeal  vertigo  have  probably  been  a  form  of  idio- 
pathic epilepsy  or  of  ataxic  laryngeal  crises,  but  the  cure  of  some  of  the  cases 
by  removal  of  a  laryngeal  polypus  or  other  gross  laryngeal  lesion  has  proven 
that  the  brain  symptoms  may  be  reflex. 

Gastric  Vertigo  may  be  the  result  of  an  acute  gastric  irritation,  produced, 
perchance,  by  indulgence  in  strawberries,  lobsters,  shell-fish,  or  some  other 
articles  of  diet  out  of  harmony  with  the  digestion  of  the  individual.  This 
vertigo  is  often  attended  with  intense  headache,  partial  blindness,  or  double 
vision,  and  is  relieved  by  vomiting. 

Chronic  gastric  vertigo,  due  to  persistent  dyspepsia,  is  a  much  rarer  affection 
than  was  supposed  by  Trousseau  and  his  followers.  In  those  cases  of  chronic 
dyspepsia  in  which  the  more  or  less  constant  vertigo  is  at  its  worst  two  to  four 
hours  before  eating  it  seems  to  me  as  rational  to  ascribe  the  vertigo  to  the  pres- 
ence in  the  blood  of  products  of  imperfect  digestion  as  to  attribute  it  to  gastric 
irritation.  In  some  dyspeptics,  however,  there  are  more  or  less  frequent  par- 
oxysms of  vertigo,  with  ocular  disturbance  and  sick  stomach,  closely  simulat- 
ing those  of  an  acute  gastric  vertigo.  It  is  ])ossible  that  the  vertigo  which 
occurs  long  after  eating  in  chronic  dyspepsia  may  sometimes  be  due  to  an  intes- 


VERTIGO.  (HI 

tinal  irritation,  as  is  iindonbtodly  the  giddiness  with  a  sense  of  weight  over  the 
brows,  or  even  of  burning  in  the  eyes,  which  may  be  the  only  manifest  symp- 
tom of  tapeworm. 

Vertigo  of  the  Special  Senses. — It  is  well  known  that  certain  rapid  changes  of 
position  produce  giddiness  with  nansea  and  vomiting,  notably  rapid  whirling, 
as  in  the  waltz,  swinging,  as  in  the  play  of  children,  and  the  rocking  motion 
of  the  ocean.  The  giddiness  in  these  cases  may  be  in  part  due  to  the  disturb- 
ance of  circulation,  but  it  seems  also  to  be  in  part  caused  by  the  special-sense 
irritation. 

Paralysis  of  the  external  rcctu.-,  and  more  rarely  of  other  eve-muscles,  often 
prodnces  a  vertigo  which  is  probably  the  result  of  the  confusion  caused  in  the 
nerve-centres  by  the  non-agreement  of  the  eyes  and  other  special-sense  organs 
in  their  representation  of  objects.  Even  when  one  eye  is  closed  the  object 
may  be  perceived  in  one  direction  by  vision  and  in  another  by  the  sense  of 
touch  or  of  the  muscular  sense,  so  that  closure  of  one  eye  does  not  always 
arrest  the  vertigo.  Nystagmus  sometimes  produces  giddiness  by  the  rapid 
changes  in  the  position  of  sensory  impressions  on  the  retina.  It  is  import- 
ant to  remember  that  whilst  an  acute  paralytic  squint  is  almost  invariably 
accompanied  by  double  vision  and  giddiness,  a  concomitant^  squint  rarely  pro- 
duces either  of  these  symptoms. 

Vertigo  is  sometimes  produced  in  man  by  injections  into  the  external  ear 
of  very  hot  or  very  cold  water ;  also  by  mechanical  interference  with  the 
Eustachian  tubes.  It  is  as  yet  uncertain  whether  such  vertigo  ought  to  be 
considered  as  really  due  to  the  disturbance  of  the  external  ear  or  as  a  purely 
reflex  phenomenon.  Any  disease  which  involves  the  aural  labyrinth  is  very 
prone  to  produce  pronounced  vertigo ;  and  intense  sudden  congestion  of  the 
inner  ear  or  apoplexy  into  the  semicircular  canals  may  cause  a  sudden  violent 
vertigo,  accompanied  by  extreme  pallor  of  the  face,  excessive  sweating,  and 
violent  symptoms  of  imminent  syncope  or  even  death.  Almost  all  forms  of 
aural  vertigo  are  spoken  of  by  writers  as  Menih^e's  disease:  the  name  should, 
however,  be  restricted  to  the  sudden  apoj)lectic  cases,  such  as  were  described 
by  Meniere  in  18G1.  Aural  vertigo  may  be  essentially  chronic  and  persist- 
ent. I  have  seen  frequent  vertiginous  attacks  produced  by  a  gunshot  wound 
in  which  the  bullet  lodged  in  the  vicinity  of  the  semicircular  canals.  The 
nature  of  an  aural  vertigo  is  to  be  made  out  by  noticing  the  deafness  or  t)ther 
evidence  of  local  disease  of  the  ear.  Meniere's  disease  must  be  distinguished 
from  Voltolini's  discciHe,  which  is  a  purulent,  labyrinthic  otitis.  In  Volt(v- 
lini's  disease  the  attack  is  accompanied  with  violent  pains  in  the  ear,  the 
unconsciousness  becomes  complete,  and  high  fever  and  delirimn  indicat*'  the 
gravity  of  the  affection. 

Toxemic  Vertigo  may  be  the  only  decided  symjjtoni  of  a   mild   uru'iiiia,  is 
vcrv  commonlv  of  litiiiomic  origin,  or  iiny  be  j)roduced  by  alcohol  oi-  various 

'  A  con(;oinitant  8r|iiint  is  one  wliiili  is  pniducid  l>y  dclVct  of  tlio  eye  ilscif.  Tlie  lael 
stated  in  the  text  ia  probably  owiiij.'  to  the  .slow  (ieveiopruent  of  the  conrdiiiiiint  -(piinl  and 
tlie  liabitual  disregard  by  ibo  brMiii-centres  of  the  viniial  itiiaRe  in  one  of  tbc  two  tycs. 


612  FUNCTIONAL   NERVOUS  DISEASES. 

otlier  poisons.  The  lithseraic  vertigo  is  often  severe  and  attended  with  some 
mental  confusion.     Its  nature  is  to  be  recognized  by  detecting  the  lithsemia. 

Essential  vertigo  represents  a  class  of  infrequent  cases  in  which  no  known 
cause  of  vertigo  can  be  discovered.  It  is  probable  that  in  the  brain  there  are 
undiscovered  centres  of  equilibration  disease  of  which  may  give  rise  to  vertigo. 

Treatment. — The  treatment  of  vertigo  resolves  itself  into  the  treatment  of 
the  disease  which  produces  the  symptom.  In  those  cases  in  which  no  dis- 
tinct cause  can  be  discovered  remedial  measures  should  be  directed  to  the 
thorough  building  up  of  the  general  health.  There  is  no  known  specific  treat- 
ment of  the  vertigo  itself. 

Epilepsy. 

Definition. — A  disease  of  unknown  pathology,  in  which  at  irregular  inter- 
vals and  without  obvious  existing  causes  an  abnormal  disturbance  of  nerve- 
force  occurs,  in  most  cases  accompanied  with  loss  of  consciousness  and  very 
frequently  by  convulsive  disturbance. 

Synonyms. — Idiopathic  epilepsy  ;  Fits  ;  Falling  sickness.- 

Etiolog-y. — The  importance  of  heredity  in  the  production  of  epilepsy  is 
shown  by  the  fact  that  of  4300  cases  collected  from  various  sources  by  Prof. 
H.  A.  Hare,  26  per  cent,  afforded  a  distinctly  neurotic  family  history.  Very 
freqnently  the  inheritance  is  direct,  the  epilepsy  attacking  vai'ious  members  of 
successive  generations  ;  but  perhaps  in  the  greater  number  of  cases  the  epilepsy 
is  an  expression  of  a  neuropathic  root-stock.  Especially  does  the  disease  inter- 
change in  different  generations  with  insanity.  Alcoholism  in  the  parent  is 
frequently  an  active  cause ;  consanguineous  marriage  has  a  distinct  but  less 
powerful  influence.  Scrofulosis,  rachitis,  extreme  poverty,  or  dissipation, 
anything  which  exhausts  the  vitality  of  the  parent  stock  and  tends  to  the  pro- 
duction of  nerve-degeneration  or  of  imperfect  development  of  the  nervous  sys- 
tem, certainly  has  an  influence  in  the  production  of  the  epileptic  diathesis. 

The  production  of  what  may  be  termed  accidental  epilepsy  by  poisons,  alco- 
holism, extreme  dissipation,  violent  emotion  such  as  fright,  peripheral  irrita- 
tion, etc.,  may  result  in  a  permanent  epilepsy,  it  being  an  established  clinical 
fact  that  when,  through  the  action  of  some  removable  cause,  the  nervous  sys- 
tem has  become  accustomed  at  irregular  intervals  to  discharge  paroxysmally 
nerve-force,  the  habitual  discharge  is  very  prone  to  continue  after  the  removal 
of  the  original  cause. 

Epilepsy  is  somewhat  more  frequent  in  males  than  in  females.  It  is  espe- 
cially a  disease  of  early  adult  life,  but  once  established  is  permanent.  Prob- 
ably about  one-third  of  the  cases  have  their  beginning  under  thirteen  years  of 
age,  two-thirds  under  nineteen,  and  the  remaining  third  under  thirty  years  of 
age ;  the  number  of  eases  occurring  after  thirty  being  so  few  as  scarcely  to 
affect  statistics. 

Symptomatology. — In  the  typical,  fully-developed  epileptiform  convul- 
sion the  first  symptom  is  a  peculiar  sensation,  first  felt  in  some  part  of  the 
body,  and  rising  from  its  seat  of  origin  up  to  the  head,  to  be  lost  in   uncon- 


EPILEPSY.  613 

sciousness.  This  so-called  aura  is  succeeded  at  once  by  a  peculiar  wild,  harsh 
scream,  known  as  the  epileptic  cry.  With  the  first  unconsciousness  a  general 
tonic  "Spasm  comes  on,  producino;  rigidity  of  the  whole  body  and  violent  distor- 
tions of  the  head,  limbs,  and  face.  The  muscles  of  the  trunk  and  abdomen 
are  rigidly  contracted.  Often  a  turning  of  the  head  and  eyes  to  one  side  is 
the  first  evidence  of  this  condition,  and  in  some  cases  not  only  the  head  but 
the  whole  bodv  rotates.  The  facial  muscles  are  violently  contracted,  usually 
most  markedly  on  the  side  toward  which  the  head  turns;  the  jaws  are  fixed 
and  often  drawn  to  one  side  ;  the  arras  are  almost  always  flexed  at  the  elbow, 
and  still  more  strongly  at  the  wrists ;  whilst  the  fingers  are  flexed  at  the  meta- 
carpo-])halangpal  joints  and  extended  at  the  others,  the  thumb  being  adducted 
into  the  palm  or  pressed  against  the  first  finger.  The  position  of  the  fingers 
is  similar  to  that  of  grasping  a  pen,  and  is  due  to  conjoint  spasmodic  contrac- 
tions of  the  interosseous  and  flexor  muscles,  as  in  the  so-called  athetosis.  The 
legs  are  extended  and  the  feet  inverted.  The  position  of  the  arms,  legs,  hands, 
and  feet  is  usually  that  which  is  assumed  in  a  case  of  universal  tonic  spasm,  the 
members  being  drawn  always  in  the  direction  of  the  muscles  of  superior  power  ; 
but  in  some  epileptic  convulsions  this  is  departed  from,  showing  that  certain 
of  the  muscles  are  more  affected  than  others.  Thus,  the  fists  may  be  clinched 
or  the  legs  may  be  violently  flexed  and  drawn  up  on  the  abdomen. 

The  stage  of  tonic  spasm  is  usually  accompanied  by  marked  pallor  of  the 
face,  and  lasts  from  a  few  seconds  to  one  or  even  two  minutes,  when  it  is  suc- 
ceeded by  the  stage  of  clonic  spasm.  Usually  the  coming  on  of  this  is  marked 
by  vibratory  tremors  passing  into  vibrations,  which  continually  grow  both 
slower  and  more  severe  until  the  intermissions  become  long  and  complete,  and 
the  limbs  are  alternately  relaxed  and  jerked  in  movements  as  wild  and  bizarre 
as  they  are  violent.  During  the  period  of  clonic  spasm  the  face  becomes  red, 
congested,  even  bloated,  and  often  livid.  The  expression  changes  continually, 
since  the  spasm  involves  all  the  muscles  of  the  face,  including  those  of  masti- 
cation and  of  the  tongue,  the  soft  palate,  and  the  larynx.  Owing  to  the  violent 
working  of  the  muscles  of  mastication  the  saliva  is  forced  from  tiie  mouth  in 
the  form  of  froth.  The  tongue  is  continually  thrust  in  and  out  by  the  spasm 
of  its  muscles,  and  is  apt  to  be  caught  between  the  convulsively  moving  jaws 
and  severely  bitten.  If  the  tongue  happens  to  be  between  the  teeth  during  the 
period  of  tonic  spasm  in  an  epileptic  convulsion,  it  is  bitten  in  the  first  stage 

of  the  fit. 

The  blood-stain  which  is  so  characteristic  upon  the  froth  is  due  to  hajmor- 
rhage  from  the  tongue.  The  pupils  at  the  beginning  of  the  fit  are  sometimes 
contracted  ;  absolutely  immovable  dilatation  occurs,  however,  very  early,  if 
indeed  it  be  not  present  from  the  onset,  and  is  the  characteristic  condition  dur- 
ing the  whole  fit.  The  return  of  the  pupils  to  the  normal  state  is  often  one  of 
the  earliest  evidences  that  the  paroxysm  has  exhausted  itself  In  some  cases 
after  the  fit  the  pupils  undergo  remarkable  oscillations.  During  the  height  of 
the  attack  both  the  pupillary  and  the  conjunctival  reflexes  are  abolished.  The 
spiiincters  arc  in  the  majority  of  (•j)ileptio  convulsions  not  relaxed,  but  it  is  not 


614  FUNCTIONAL    NERVOUS   DISEASES. 

rare  for  the  urine  and  faeces  to  be  passed,  and  Gowers  affirms  that  this  is  more 
apt  to  occur  in  nocturnal  fits.  The  pulse,  in  the  beginning  feeble  or  of  normal 
force,  during  the  height  of  the  paroxysms  is  greatly  increased  in  frequency  and 
in  force.  M.  Magnon  states  that  during  the  tonic  stage  the  pulse-rate  falls, 
and  the  rhythm  is  altered  so  that  a  complete  systole  and  diastole  may  occupy 
six  times  the  normal  period.  During  the  clonic  convulsion  the  respiration  is 
noisy,  stertorous,  slow,  or  even  irregular :  often  the  pauses  between  the  acts 
are  so  long  that  the  patient  seems  to  have  stopped  breathing,  and  when  death 
occurs  in  a  fit  it  is  by  the  persistence  of  such  arrest  of  respiration. 

During  the  convulsion  of  epilepsy  the  bodily  temperature  may  remain 
about  the  norm,  but,  if  the  attack  be  prolonged,  usually  rises,  very  rarely, 
however,  going  above  102°.  During  the  status  epilepticus  the  temperature 
of  107°  may  be  reached. 

The  stage  of  clonic  convulsion  lasts  from  three  to  four  minutes,  when  it 
merges  into  the  conditi(m  of  quiet  coma,  and  this  in  turn  passes  into  a  heavy 
sleep,  which  may  continue  for  a  few  moments  or  for  hours.  After  the  waking 
the  patient  suffers  from  headache  and  general  muscular  soreness. 

The  description  which  has  just  been  given  represents  the  epileptiform  con- 
vulsion as  it  is  seen  in  what  may  be  considered  typical  epilepsy  ;  but  even  in 
the  majority  of  cases  of  epilepsy  some  of  the  phenomena  are  wanting,  and 
almost  any  of  them  may  be  absent.  The  essential  or  central  idea  of  the  epi- 
leptiform convulsion  is  the  occurrence  of  complete  unconsciousness,  with  nervous 
discharge  taking  the  form  of  a  clonic  spasm,  in  which  the  movements  have  no 
relation,  apparent  or  real,  to  those  of  ordinary  life. 

It  must  never  be  forgotten  that  the  epileptiform  convulsion  in  its  most 
typical  manifestations  may  arise  from  causes  other  than  epilepsy,  and  also  that 
epilepsy  may  give  rise  to  convulsive  and  other  nervous  disturbances  replacing 
the  epileptiform  convulsion,  but  entirely  different  from  it  in  their  phenomena, 
l^efore  considering  these  anomalous  epilepsies  I  shall  discuss  in  more  detail  one 
or  two  of  the  more  important  symptoms  of  the  convulsive  attack. 

The  epileptic  cri/  is  probal)ly  due  to  a  forcing  of  air  by  the  convulsive  con- 
tractions of  the  respiratory  muscles  through  a  glottis  narrowed  by  spasm  of 
the  vocal  cord.  It  is  commonly  single,  but  may  be  repeated,  although  much 
repetition  should  always  raise  the  suspicion  that  the  attack  is  hysterical. 

The  aura  is  often  absent.  When  present  it  usually  arises  in  one  extremity 
or  in  the  stomach,  although  psychical  and  special-sense  auras  do  occur,  and  in 
some  cases  warnings  are  given  by  bilateral  tremors  or  starts  in  the  limbs,  or 
by  widespread  indefinable  sensations,  which  may  perha[)S  be  looked  upon  as 
generalized  auras.  Various  as  the  auras  are  in  different  individuals,  they  are 
remarkably  constant  in  the  one  subject,  each  epileptic  paroxysm  conforming  to 
those  that  have  ])re('ed('(l  it. 

An  aura  which  commences  in  an  extremity  is  usually  first  felt  in  the  hand, 
but  it  may  begin  in  the  foot.  From  the  hand  it  rises  up  the  arm  as  an  inde- 
.scribable  sensation,  and  is  not  rarely  traced  by  the  patient  to  the  neck,  where 
it  disap{>ears  in  the  development  of  unconsciousness.     The  gastric  aura  is  very 


EPILEPSY. 


i)|.> 


frequent.  It  is  variously  described — as  pain,  as  burning,  as  a  sense  of  cold- 
ness, as  trembling,  but  more  oi'trii  as  an  indelinite  distress.  Usually  there  is 
no  sensation  of  rising  connected  with  it,  but  in  some  cases  this  occurs.  An 
aura  may  be  first  felt  in  the  chest,  and  ascend  to  the  throat,  when  it  gives  rise 
to  choking  sensations.  It  may  also  begin  in  the  face,  tongue,  larynx,  pharynx, 
or  indeed  in  any  part  of  the  body.  In  psychical  aura  the  emotion  is  almost 
always  that  of  alarm  or  excessive  terror.  In  very  rare  cases  a  very  ])eculiai' 
idea  ushers  in  the  epileptic  convulsion,  constituting  a  true  intellectual  aura. 

Special-sense  auras  are  rare,  the  gustatory  being  the  most  infrequent,  the 
ocular  the  most  frequent.  The  ocular  aura  may  consist  in  seeing  colors  ;  in  an 
apparent  increase  or  lessening  in  the  size  of  objects;  in  indescribable  visual 
sensations;  in  double  vision,  or  in  loss  of  distinctness  of  sight,  deepening,  it 
may  be,  into  complete  blindness.  In  a  few  cases  there  are  actual  visions,  either 
simple  or  complex.  In  the  auditory  aura  abnormal  sounds  are  heard,  such  as 
hissing  or  the  whizz;  of  rushing  steam,  or  intermittent,  pulsating  noises,  such 
as  beating  of  drums  or  music,  and  in  very  infrequent  cases  even  a  spoken  word. 
The  olfactory  aura  seems  always  to  take  the  form  of  a  bad  smell. 

The  rate  of  the  aura  varies  very  greatly.  When  it  is  slow  enough  to  allow 
of  the  institution  of  proper  measures  the  fit  can  usually  be  aborted. 

According  to  the  observations  of  \\^est{)hal  and  of  Gowers,  none  of  the 
myotatic  contractions  can  be  obtained  immediately  after  a  very  severe  epileptic 
fit,  but  after  about  half  a  minute  the  knee-jerk  reappears,  and  frequently 
becomes  excessive ;  ankle-clonus  may  also  be  temj)orarily  present. 

The  most  important  of  the  anomalous  epilepsies  is  that  which  is  known  as 
''■petit  mal''  or  the  little  sickness,  in  contrast  to  the  larger  attacks,  which  are 
known  as  '^  ep-os  maV  In  its  more  ordinary  form  i)etit  mal  consists  of  a 
momentary  loss  of  consciousness,  accompanied  by  pallor  of  the  face,  which  is 
not,  however,  invariably  present.  The  sufferer,  in  the  midst  of  a  conversation, 
suddenly  stops,  is  quiet  for  a  few  seconds,  and  then  takes  up  the  thread  of  dis- 
course as  though  nothing  had  hai)pcned,  being  in  fact  unconscious  that  any- 
thing has  happened.  Sometimes  the  period  of  (;onsciousness  is  followed  by  a 
state  of  confusion  of  thought. 

It  must  be  borne  in  mind  that  every  grade  of  attack  occurs  in  nature 
between  the  mildest  and  briefest  paroxysm  of  petit  mal  and  the  most  severe 
convulsion.  Sometimes  the  unconsciousness  is  acconq)anied  with  great  muscu- 
lar relaxation  and  a  fall  to  tiie  earth,  without  further  synq)tom.  Sometimes 
the  petit  mal  is  ushered  in  by  a  distinct  aiu-a  or  even  a  single  loud,  piercing 
scream,  which  may  not  be  followed  bv  motor  disturbance.  So  variable  and  so 
frequently  absent  is  tiie  convulsive  |)ortion  of  the  c])ilcptic  paroxysm  that  the 
unconsciousness  is  usually  considered  as  the  essenti.il  jxirtion  of  (lie  epileptic 
paroxysm.  I  am  sure,  however,  that  in  :in  (•|)ilei)tic  atta(;k  consciousness  may 
be  preserved.  In  a  case  which  was  probably  one  of  epilepsy,  and  in  which,  so 
long  as  I  had  opportiniity  for  watching  the  synq)tonis,  llicrc  w:is  no  change, 
the  patient  had  a  distinct  aura  in  (lie  hand,  rising  up  llie  arm  in  the  usual 
manner.  l)nt  sufferiii'j  arrest  in  the  neck,  at  whieli  time,  without  any  loss  of  con- 


616 


FUNCTIONAL    NERVOUS   DISEASES. 


sciousness,  there  were  violent  convulsive  movements  of  the  muscles  below  the 
position  to  which  the  aura  had  reached. 

Further,  I  am  sure  that  the  epileptic  paroxysm  may  show  itself  simply  as 
a  sensory  disorder  which  resembles  an  epileptic  paroxysm  cut  off  at  the  end  of 
the  aura  stage.  Thus  I  have  seen  in  various  children  paroxysms  in  which  the 
child  would  crv  out  with  a  sudden  painful  sensation  in  its  stomach,  become 
extremely  pallid,  run  to  its  mother,  be  held  for  a  moment,  and  the  whole 
attack  would  be  over,  there  being,  at  least  in  some  of  these  attacks,  no  loss  of 
consciousness.  That  these  cases  represented  true  epilepsy  has  been  demon- 
strated by  their  continuance  in  spite  of  all  treatment;  by  the  regularity  of 
their  occurrence  ;  and,  beyond  all,  by  the  fact  that  I  have  watched  them 
develop  into  fully-formed,  unmistakable  epilepsy. 

When  the  epileptic  paroxysm  occurs  only  at  night  (nocturnal  epilepsy),  its 
existence  may  be  entirely  overlooked.  Sometimes  the  patient  wakes  before  the 
occurrence  of  the  paroxysm,  but  very  frequently  he  passes  directly  from  the 
unconsciousness  of  sleep  to  the  unconsciousness  of  the  epileptic  convulsion,  and 
on  waking  in  the  morning  has  no  knowledge  of  what  has  occurred,  although 
usually  there  is  much  malaise  and  general  physical  weariness.  A  bitten  tongue 
in  such  cases  ought  to  reveal  the  occurrence  of  the  night.  Frequently,  but  not 
by  any  means  universally,  the  urine  is  passed  during  the  attack,  and  whenever 
a  new  habit  of  wetting  the  bed  at  night  is  formed  during  late  youth  or  early 
adult  life  suspicion  should  be  aroused. 

The  most  characteristic  feature  of  the  movements  of  ordinary  epilepsy  is 
the  absence  of  apparent  purposiveness,  but  in  anomalous  epilepsy  this  charac- 
teristic may  be  wanting,  as  in  procursive  epilepsy  and  epileptic  automatism. 

In  epilepsia  procursiva,  either  with  or  without  a  primary  epileptic  cry,  the 
subject  starts  on  a  run,  either  forward  or  in  a  circle,  and  after  a  greater  or  less 
time  wakes  up  or  falls  in  a  violent  clonic  convulsion.  I  have  seen  the  arrest 
of  such  a  patient  by  force  change  the  attack  of  running  into  a  clonic  convulsion. 
This  procursive  epilepsy  is  rarely  preceded  by  an  aura;  is  often  but  not  always 
associated  with  organic  disease  of  the  brain  ;  occurs  usually  but  by  no  means 
universally  in  young  subjects ;  may  continue  for  years  unchanged  or  be  trans- 
formed into  an  ordinary  epilepsy,  during  the  transformation  the  attacks  being 
MOW  this,  now  that,  form.  It  is  said,  also,  to  be  frequently  associated  with 
moral  degradation. 

In  a  paroxysm  of  epileptic  automatism  the  subject  performs  simple  or  com- 
plicated acts  apparently  involving  the  possession  of  consciousness,  and^yet  is  in 
the  condition  in  which  he  has  no  proper  control  or  knowledge  of  himself  or  of 
his  surroundings.  The  relations  of  epileptic  automatism  to  double  conscious- 
ness are  very  close.  The  condition  may  precede  or  may  follow  the  convulsive 
attack,  the  patient  running,  singing,  dancing,  laughing,  gesticulating,  or  doing 
other  bizarre  actions,  and  then  falling  in  a  convulsion.  Epileptic  automatism 
is,  however,  usually  a  ])()st-paroxysmal  phenomenon,  and  occurs  more  frequently 
after  a  minor  than  after  a  major  epileptic  attack.  In  its  simplest  form  the 
automatism  consists  of  doing  something  which  is  usually  incongruous,  such  as 


EPILEPSY.  617 

undressing  regardless  of  surrounding  circumstances,  seizing  and  secreting  about 
the  person  small  objects,  cutting  bread  and  buttering  it  and  eating  it  as  fast  as 
possible,  etc.  etc.  Sometimes  the  series  of  acts  are  so  apparently  rational  and 
purposiv^e  that  it  is  almost  impossible  to  persuade  bystanders  that  the  patient  is 
not  conscious.  Gowers  relates  a  case  in  which  a  London  cabman  would  drive 
through  the  most  crowded  streets  of  IjoikIou  without  accident ;  and  a  woman 
under  mv  own  care  would  continue  whatever  act  she  was  doina;  at  the  time  of 
the  convulsion.  Thus,  when  preparing  a  meal  she  would  fall  into  a  convidsion, 
get  up  in  two  or  three  minutes,  and  continue  to  dish  up  the  dinner,  arrange  the 
plates,  etc.  in  an  apparently  natural  way,  but  after  a  time  would  suddenly  wake 
up  and  have  no  knowledge  of  what  she  had  been  doing. 

In  many  cases  of  epileptic  automatism  no  display  of  emotion  is  made : 
sometimes,  howev^er,  the  patient  is  hilarious,  and  even  aggressively  affectionate, 
and  still  more  frequently  rage  or  violent  emotion  is  manifested.  It  is  through 
cases  in  which  violent  passion  asserts  itself  that  epileptic  automatism  passes  into 
the  so-called  epileptic  mania,  which,  indeed,  may  be  very  logically  considered  as 
a  form  of  the  automatism  associated  with  excited  emotions. 

In  maniacal  epileptic  automatism,  so  called,  there  is  violent  excitement  and 
delirium,  which  may  take  the  form  of  an  acute  mania  or  of  an  agitated  melan- 
choly :  in  either  case  the  incoherence  is  usually  less  than  in  the  corresponding 
non-epileptic  aifection.  Not  rarely  after  a  primary  period  of  violent  discon- 
nected speech  the  patient  is  seized  with  an  ambitious  or  mystic  delirium,  or 
sometimes  a  delirium  of  persecution,  or,  more  rarely,  with  an  erotomania,  in 
which  sentence  after  sentence  flows  out  with  extraordinary  volubility.  The 
attack  usually  comes  on  suddenly,  and  is  always  accompanied  by  hallucinations, 
which  sometimes  develop  brusquely  or,  more  rarely,  in  the  course  of  a  few 
minutes.  The  hallucinations  affect  all  the  senses  and  give  rise  to  delusions 
which  conform  with  the  type  of  the  emotional  disturbance.  The  delirium  may 
last  for  a  few  moments  or  several  days.  It  is  especially  characterized  by  the 
tendency  to  acts  of  extreme  violence — to  suicide  in  the  melancholic  form  and  to 
homicide  in  the  maniacal  variety. 

In  epileptic  fury  the  subject  has  no  control  over  his  actions,  and  when  mur- 
der and  other  crimes  are  committed  it  is  imjiortant  that  the  medical  jurist  recog- 
nize the  true  nature  of  the  attack.  When  the  mania  is  of  mild  type  the  danger 
of  overlo(jking  its  character  is  greatest.  The  diagnosis  is  to  be  made  by  obtain- 
ing the  history  of  previous  attacks  of  epilepsy,  by  the  brutality  and  causeless- 
ness  of  tlie  crime,  and  especially  by  the  fact  that  the  patient  has  no  memory  of 
wcurrences  which  took  place  during  the  mania.  In  a  cr'rtain  proportion  of  the 
cases  the  attacks  of  epileptic  mania  are  rejieatcd  in  exact  counterfeit  one  of  the 
other.  The  maniacal  outbreak  may,  however,  not  recur  I'or  a  great  length  of 
time.  The  difficulties  of  the  expert  arc  increased  by  the  fact  that  the  first 
j)aroxysm  of  an  epilepsy  may  take  the  form  of  a  furious  outbreak  of  epileptic 
mania.  Under  these  circumstances  it  nuiy  be  essential  that  the  paticMit  be  kept 
for  a  length  of  time  under  surveillance,  since,  ahhough  the  circumstances  of 
the   f»aroxvsm   may  satisfy  the  mind  of  the  medical  expert,  they  may  fail  to 


618  FUNCTIONAL    NERVOUS   DISEASES. 

carry  conviction  to  judge  and  jury.  Esquirol  states  that  the  homicidal  mania 
of  epilepsy  is  never  radically  cured,  and  that  its  subject  is  always  liable  to  a 
fresh  outbreak.  Whether  this  be  absolutely  true  or  not,  it  is  certain  that  the 
recurrence  is  sufficiently  habitual  to  demand  the  perpetual  surveillance  of  the 
epileptic  criminal. 

Epilepsy  frequently  leads  to  mental  degradation,  which  may  end  in  com- 
plete dementia.  More  rarely  a  permanent  insanity  develops  in  the  epileptic, 
although  it  is  doubtful  whether  the  convulsions  in  these  cases  are  not  simply 
the  outcome  of  an  original  neurotic  vice  which  is  also  the  cause  of  the  insan- 
ity. The  type  of  such  insanity  is  said  to  be  usually  melancholic,  with  delu- 
sions of  persecution  -and  suicidal  impulses.  The  characteristic  mental  state  of 
chronic  epilepsy  is  progressively  lowered  niental  power,  wj_th  a  peculiar  irrita- 
bjlity  and  brutal  selfishness,  and  outbreaks  of  furious  anger  on  the  slightest 
provocation.  Even  while  the  mental  powers  are  still  active  epileptics  very 
frequently  are  peculiarly  irritable  and  revengeful.  After  a  paroxysm  these 
tendencies  are  increased. 

The  term  Cardiac  Epilepsy  has  been  given  to  a  peculiar  form  of  par- 
oxysmal attacks  with  convulsive  movements  in  which  it  is  doubtful  whether 
the  nervous  or  the  circulatory  disturbance  should  be  considered  primary. 
There  are  two  forms  of  this  affection. 

In  Syncopal  Cardiac  Epilepsy  the  habitual  pulse- rate  is  much  below  the 
norm,  and  at  the  moment  of  the  attack  diminishes  to  twelve,  ten,  or  even 
five  per  minute.  The  paroxysm  may  be  ushered  in  b}'^  an  aura ;  the  face,  at 
first  pale,  afterward  becomes  congested  ;  the  respiration,  at  first  often  quick- 
ened, is  labored  and  stertorous  ;  the  bodily  temperature  usually,  if  not  always, 
falls,  in  some  cases  very  distinctly.  Not  rarely,  directly  before  the  paroxysm, 
the  patient  complains  bitterly  of  intense  coldness.  Whilst  unconscious  the 
})atient  may  be  quiet,  but  general  or  more  frequently  partial  convulsions,  with 
or  without  biting  of  the  tongue,  are  not  infrequent  phenomena. 

In  the  Congestive  Cardiac  Epilepsy  there  is  during  the  attack  excessively 
violent  heart-action,  with  intense  congestion  of  the  head,  giving  rise  to  deep 
flushing,  to  the  formation  of  punctate  ecchymoses,  and  even  to  general  oozing 
of  blood  from  the  face.  The  conjunctiva  is  usually  extraordinarily  congested 
and  swollen,  and  often  bleeds  freely.  Not  rarely  violent  haemorrhage  from 
the  nose  occurs.  I  have  never  seen  the  attack  commence  with  an  aura,  but 
the  convulsive  movements  may  be  very  violent. 

Diag-nosis. — In  discussing  the  diagnosis  of  epilepsy  it  seems  best,  first,  to 
consider  the  anomalous  forms  of  epilepsy  ;  second,  the  relations  of  idiopathic 
epilci)tiform  convulsions  to  other  forms  of  convulsions. 

Tiie  diagnosis  of  anomalous  epilej)sy  becomes  easy  when  it  is  recognized 
that  the  essential  character  of  idiopathic  epilepsy  is  a  tendency  to  an  abnoi-mal 
discharge  of  nerve-force  at  irregular  intervals  and  without  obvious  cause,  but 
dependent  upon  some  persifiient,  usually  irremediable,  state  of  the  nervous  system. 
Such  being  the  fact,  whenever  during  late  childhood  or  early  adult  life 
peculiar  paroxysmal  attacks  occur,  evidently  not  of  hysterical  origin  nor  yet 


EPILEPSY.  619 

due  to  irritation,  to  abuse  of  alcoholic  or  sexual  ])lea?nres,  or  to  any  other 
assignable  cause,  the  practitioner  should  suspect  the  presence  of  an  aberrant 
epilepsy.  It  is,  however,  very  unwise  to  express  such  an  opinion  too  hastily, 
and  only  after  the  failure  of  long-continued  treatment  to  effect  a  cure  should 
the  probable  nature  of  the  attacks  be  explained  to  the  parents  or  immediate 
friends  of  the  patient. 

The  convulsions  produced  in  childhood  by  the  peripheral  irritations,  etc. 
are  distinguishable  from  epileptic  fits  only  by  the  failure  of  repetition.  It 
must  be  remembered  that  what  may  be  called  the  convulsive  diathesis  in  the 
child  is  closely  associated  with  the  epileptic  diathesis,  and  that  in  a  large  pro- 
portion of  cases  of  epilepsy  there  is  a  history  of  repeated  convulsions  during 
childhood.  Some  children  are  evidently  born  with  a  convulsive  tendency  so 
firmly  fixed  in  the  nervous  system  that  its  possessor  is  doomed  from  birth  to  a 
hopeless  epilepsy.  On  the  other  hand,  there  are  individuals  in  whom  the  epi- 
leptic tendency  originally  exists,  but  in  so  slight  a  degree  as  to  be  amenable  to 
hygienic  and  medicinal  treatment.  Such  an  individual  may  during  childhood 
suffer  from  repeated  attacks  of  accidental  convulsions  and  become  epileptic,  or 
by  great  care  the  early  convulsions  may  be  prevented,  the  diathesis  or  tendency 
be  overcome,  and  the  nervous  system  be  allowed  to  harden  into  the  nornuil 
mould. 

The  characteristics  of  the  hysterical  convulsion,  as  contrasted  with  the  epi- 
leptiform, are  the  peculiar  disturbances  of  consciousness  (see  Hysteria,  page 
597) ;  the  presence  of  emotional  disorder ;  and  the  tendency  of  the  muscular 
contractions  to  affect  only  a  part  of  the  body,  to  simulate  in  an  exaggerated 
form  natural  movements,  and  to  become  tetanic.  Persistently  clonic  spasms 
pertain  especially  to  the  epileptiform  convulsion,  whilst  persistent  tetanic 
rigidity  is  highly  characteristic  of  hysteria. 

Although  usually  the  true  nature  of  hystero-epilcpsy  can  be  recognized, 
there  are  cases  in  which  .it  is  necessary  to  reserve  the  diagnosis  until  the 
patient  has  long  been  watched.  It  must  also  be  remembered  that  pronounced 
hysterical  phenomena  may  immediately  follow  a  purely  epileptic  convulsion. 
Nocturnal  epileptiform  attacks,  in  which  the  ])atieut  passes  without  waking 
into  the  convulsion,  are  probably  never  hysterical. 

It  is  necessary  also  to  distinguish  from  idiopathic  epilepsy  epileptic  convul- 
sions due  to  peripheral  irritation,  or  "  reflex  epilepsy  ;  "  epileptiform  convulsions 
due  to  violent  poisonings  from  within  or  without  the  body,  or  "toxa^mic  epi- 
lej)sy  ; "  and  epileptiform  convulsions  due  to  organic  brain  disease,  or  "organic 
epilepsy." 

The  age  at  which  the  e|)il('ptic  paroxysm  has  first  apjieared  is  a  matter  of 
vital  importance  in  the  diagnosis  between  i(lio])athi(!  epilepsy  nnd  the  diseases 
wliich  simulate  it.  It  may  be  laid  down  as  a  ride  of  sufficient  accuracy  for 
practical  guidance,  and  having  very  rare  if  any  exceptions,  that  an  epilepsy 
■which  develops  offer  the  thirty-jiflh  year  of  nr/e  i.t  not  idiopathic,  hut  is  due  to 
some  orr/anic  brain  disease,  to  the  nhiise  of  ah-ohol,  rejiex  irritfdion,  or  other 
caxLsea,  vjhich  in  some  cases  may  fte  so  hidden,  as  to  be  exceed iv(/ly  dij/indt  of 


620  FUNCTIONAL    NERVOUS   DISEASES. 

recognition.  An  epilepsy  which  first  appears  after  the  thirteenth  year  should 
be  viewed  with  great  suspicion.  In  my  own  experience  epilepsy  occurring 
between  the  age  of  thirty-five  and  fifty-five,  not  dependent  upon  assignable 
causes  unconnected  with  organic  brain  disease,  has  in  at  least  80  per  cent,  of 
the  cases  been  due  to  brain  syphilis. 

Tlie  nature  of  an  Organie  Epilepsy  is  often  indicated  by  the  character  of 
the  attack.  In  idiopathic  epilepsy  the  convulsion  rarely  begins  habitually  in 
one  extremity.  Sucii  mode  of  onset,  and  especially  the  confinement  of  the 
movements  to  one  limb,  one  side  of  the  face,  or  other  muscular  territory, 
should  arouse  the  grave  suspicion  of  Jacksonian  epilepsy  due  to  organic  focal 
brain  disease.  An  idiopathic  epilepsy,  or  at  least  an  epilepsy  in  which  no 
change  can  be  demonstrated  in  the  nerve-centres,  may,  however,  take  on  the 
Jacksonian  type,  so  that  in  any  case,  before  giving  a  positive  opinion,  it  is 
wisest  to  wait  for  other  symptoms  of  organic  brain  disease ;  but  here  it  must 
also  not  be  forgotten  that  a  temporary  aphasia  and  a  hemiplegic  or  monoplegic 
paresis  may  follow  a  paroxysm  of  idiopathic  epilepsy. 

Reflex  Epilepsy  is  not  to  be  distinguished  by  any  peculiarities  in  the  convul- 
sion, biit  only  by  finding  the  cause  of  the  irritation  and  noting  the  effect  of  its 
removal.  It  must,  therefore,  be  an  invariable  rule  for  the  practitioner  to  search 
thoroughly  every  epileptic  individual  for  points  of  irritation.  Wounds  of  the 
head  or  other  portions  of  the  body,  astigmatism  and  other  imperfections  of  the 
eyes,  diseases  or  malformations  of  the  nasal  cavity,  carious  teeth  and  retained 
milk  teeth,  aural  disease,  adherent  prepuce  or  other  irritation  of  the  genital  or- 
gans, intestinal  worms, — are  among  the  irritations  which  have  in  very  many 
cases  provoked  a  reflex  epilepsy.  The  importance  of  thorough  examination  is 
increased  by  the  fact  that  the  reflex  epilepsy  may  engender  the  epileptic  habit. 

Of  the  Toxcemic  Epilepsies  the  most  important  is  the  alcoholic,  which  may 
simulate  very  closely  not  only  major  epilepsy,  but  the  simple  epileptic  vertigo 
or  petit  mal.  Not  rarely  the  attack  is  ushered  in  by  headache,  gastric  embar- 
rassment, troubles  of  vision,  excessive  tremors,  or  some  similar  prodrome  which 
may  closely  resemble  an  aura,  and  probably  is  of  the  nature  of  an  aura.  The 
alcoholic  convulsions  often  occur  in  paroxysms,  two,  three,  four,  or  more,  one 
after  the  other,  at  intervals  of  a  few  moments,  and  are  not  rarely  followed  by 
a  temporary  mental  derangement  which  may  take  the  form  of  acute  dementia, 
during  which  the  subject  is  reduced  to  the  condition  of  an  automaton,  obey- 
ing immediately  and  mechanically  all  impulses  from  without.  Uraemic  and 
plumbic  convulsions  may  also  closely  simulate  an  idiopathtic  epilepsy.  In  all 
cases  of  toxsemic  epilepsy  the  diagnosis  must  rest  upon  the  history  of  the  case 
and  the  presence  of  other  symptoms  of  poisoning. 

Much  aid  in  the  diagnosis  between  uraemic,  hystero-epileptic,  and  epileptic 
convulsions  can  be  obtained  by  a  study  of  the  temperature.  Uraemic  convid- 
sions  are  usually,  but  not  always,  accompanied  by  fall  of  temperature.  In  the 
severe  isolated  epileptic  attack  the  temperature  often  rises  very  distinctly,  and 
when  there  is  a  prolonged  series  of  fits,  connected  by  coma  and  occurring  at 
short  intervals,  the  temperature  rises  steadily.     The  single  hystero-epileptic 


EPILEPSY.  621 

attack  is  accorapanierl  only  by  a  slio;ht  rise  of  temperature,  and  when  a  series 
of  convulsions  are  the  expression  of  the  hystero-epilepsy,  the  temperature  falls 
very  rapidly  immediately  after  each  convulsion,  and  does  not  after  successive 
attacks  reach  distinctly  higher  than  in  the  first. 

Prognosis. — So  far  as  the  continuance  of  the  paroxysms  is  concerned,  the 
prognosis  in  idiopathic  epilepsy  should  always  be  very  guarded.  Traumatic, 
toxemic,  reflex,  and  organic  epilepsies  may  be  cured,  but  absolute  cures  of 
idioj)athic  epilepsy,  if  they  ever  occur,  are  most  exceedingly  rare.  Much, 
however,  can  be  done  to  ameliorate  the  attacks  and  render  them  less  fre<pient. 

Death  is  exceedingly  rare  in  a  true  epileptic  fit,  although  occasionally  a 
patient  dies  in  the  status  epilepticus.  A  fatal  termination  from  the  accidents 
produced  by  the  fit,  such  as  falling  into  the  water  or  fire  or  from  a  height,  or 
suffocation  from  vomited  food  getting  into  the  larynx  or  the  patient  lying  upon 
his  face  in  a  soft  bed,  is  more  frequent.  Notwithstanding  these  facts,  in  the 
majority  of  cases  epilepsy  does  not  very  materially  shorten  life. 

The  question  as  to  the  intellectual  future  of  an  epileptic  patient  is  always 
a  very  serious  one.  In  a  considerable  proportion  of  cases  the  disease  ends  in 
mental  and  moral  degeneration.  Although  the  resistance  of  the  brains  of 
different  individuals  to  retrograde  changes  from  epileptic  disturbances  varies 
very  greatly,  three  general  rules  may  assist  the  practitioner  in  casting  the  horo- 
scope :  first,  the  younger  the  age  at  which  the  epilepsy  commences  the  greater 
the  probabilities  of  serious  mental  deterioration  ,  second,  very  rarely  if  ever 
is  there  any  distinct  recovery  of  power,  so  that  symptoms  once  established  are 
usually  permanent;  third,  the  more  frequent  and  severe  the  fits  the  greater  the 
chances  of  intellectual  ruin. 

Epilepsy  does  not,  however,  always  end  in  mental  degradation  even  when 
the  attacks  are  frequent  and  violent  and  have  come  on  early  in  life.  I  have 
known  very  bad  epileptics  to  pursue  with  activity  and  success  a  business,  or 
even  a  professional,  life.  When  the  epilepsy  has  existed  some  years  without 
producing  any  serious  intellectual  results,  the  chances  are  always  in  favor  of 
the  escape  of  the  patient  from  such  results.  It  is  also  necessary  not  to  mis- 
take hysterical  symptoms,  such  as  emotional  excitement,  pseudo-convulsions, 
and  even  pseudo-mania  occurring  in  the  epileptic  patient,  for  symj)toms  truly 
epileptic  and  evidences  of  permanent  intellectual  and  moral  change.  Chronic 
epilepsy  may  be  so  closely  associated  with  the  hysteria  which  it  j)robably  pro- 
duces as  to  make  it  almost  impossible  to  unravel  the  mixed  symjitoms.  The 
importance  of  this  lies  in  the  fact  that  hysterical  mental  disturbance  in  e|)ilep- 
tics  often  disapjiears. 

Patholog-y. — Almost  every  conceivable  form  of  organic  le>i(iii  has  been 
found  in  the  brain  of  epilejitics,  but  the  mere  variety  and  incoiisisteiiey  of 
these  lesions  demonstrate  tliat  tiny  are  results  or  com|)lications,  and  not  the 
causes,  of  the  epile|)sv — a  conclusicju  which  receives  positive  confirmation  in 
the  fact  that  very  frer|ueiitly  no  grave  lesion  can  be  foun<l  in  (he  brain  of  ej)i- 
lepties.      Whether  the  recent  conclusions  of  Chasliii'  will  he  eventually  estab- 

'  (;liarc()t's  Arrhiirn  exi>friiiuid<il,  Jilin,  1891. 


622  FUNCTIONAL    NERVOUS   DISEASES. 

lished  is  at  present  writing  uncertain,  but  these  conclusions  are  sufficiently 
remarkable  and  plausible  to  be  cited  here.  This  observer  claims  to  have  found 
in  epileptics,  as  a  characteristic  lesion,  a  form  of  cerebral  degeneration  in  which 
the  changes  in  the  neuroglia  are  the  result  of  a  vice  of  development  which  is 
ordiuarily  dependent  upon  heredity.  According  to  the  author,  this  "  gllosi'i" 
is  a  non-inflammatory  degeneration  in  which  the  neuroglia  of  the  brain  is 
transformed  into  an  abnormal  tissue  composed  of  bundles  of  fibrillar  much 
longer  and  much  more  distinct  than  those  in  normal  brain-tissues.  The  nerve- 
cells  are  reduced  in  size  and  number,  with  their  })rocesses  shrunken  or  alto- 
gether removed  ;  the  capillaries  are  for  the  most  part  completely  intact,  without 
that  cellular  infiltration  of  their  walls,  and  especially  of  their  sheaths,  which 
is  so  pronounced  in  inflammatory  sclerosis.  Some  of  the  capillaries,  however, 
are  dilated,  and  occasionally  there  is  one  with  its  walls  thickened. 

The  scope  of  the  present  volume  does  not  allow  space  for  discussion  of  the 
various  theories  which  have  been  and  are  in  vogue  as  to  the  cause  of  the 
epileptic  attacks.  A  brief  mention  of  one  or  two  of  these,  however,  seems 
necessary. 

In  accordance  with  the  vaso-motor  theory,  the  convulsion  is  due  to  a  sud- 
den over-action  of  the  vaso-motor  centre  in  the  medulla,  and  consequent  brain 
ansemia.  This  theory  is  not  plausible,  and  really  fails  entirely  to  account  for 
anything,  as  it  fails  to  show  any  reason  for  the  disordered  action  of  the  vaso- 
motor centre.  It  seems  to  me  certain  that  no  disorder  of  the  vaso-motor 
centre  could  produce  an  epileptic  attack.  A  second  theory  is  that  of  the  dis- 
charging lesion  in  the  brain  cortex.  In  accordance  with  this,  the  cortical  cells 
become  at  irregular  intervals  so  surcharged  with  nerve-force  that  an  overflow 
occurs  and  produces  a  general  nervous  disturbance.  This  theory,  like  the  one 
previously  mentioned,  fails  to  show  the  cause  of  the  epilepsy,  but  plausibly 
explains  the  mechanism  of  the  paroxysm. 

Treatment. — In  the  so-called  reflex  epilepsy  the  removal  of  the  cause  of  the 
irritation  is  of  primary  importance.  When  in  any  case  the  disease  has  followed 
blows  upon  the  head  severe  enough  to  cause  laceration  of  the  scalp  or  injure  the 
skull,  the  old  cicatrix  of  the  wound  should  at  once  be  removed,  and  if  durinor 
the  operation  evidences  of  depression  should  be  discovered,  trephining  should 
be  performed.  When  no  evidences  can  be  obtained  of  local  injury  to  the  skull, 
and  no  good  result  hds  followed  removal  of  the  scar,  the  question  as  to  whether 
trephining  should  be  performed  or  not  becomes  a  very  serious  one.  My  own 
opinion  is  that  unless  some  reason  for  doing  otherwise  exists  the  case  should 
be  operated  upon.  In  the  majority  of  instances  the  operation  will  probably 
fail  to  do  permanent  good  ;  occasionally  it  will  give  brilliant  results  ;  and,  as 
it  is  not  possible  to  decide  beforehand  in  which  category  anv  individual  case 
will  eventually  fall,  and  as  the  o])eration  carefully  performed  in  accordance  with 
modern  methods  is  very  rarely  fatal,  it  seems  to  me  that  in  so  incurable  a  dis- 
order as  epilei)sy  it  is  wisest  to  give  the  patient  the  benefit  of  the  doubt.  In 
every  case,  however,  the  situation  should  be  carefully  explained  to  the  parents 
of  the  patient,  or  to  the  patient  himself  if  of  sufficient  age,  and  no  operation 


EPILEPSY.  623 

should  be  performed  contrary  to  the  wishes  of  the  person  or  persons  concerne<l. 
Careful  antiepileptic  treatment  after  the  removal  bv  operation  of  the  original 
irritation  is  most  essential.  The  epileptic  habit,  once  set  up,  has  in  itself  the 
probability  of  life,  and  very  commonly  the  only  cH'ect  of  the  removal  of  the 
original  cause  is  to  make  a  case  amenable  to  treatment.  It  may  well  be  that,  left 
to  itself,  such  a  case  will  soon  lose  all  the  possibility  of  the  benetit  which  might 
have  been  derived  from  the  operation  by  the  judicious  after-use  of  remedies. 

In  Idiopathic  Epilepsy,  when  it  is  possible,  the  epileptic  paroxysms  should 
be  arrested  in  the  first  stage  by  mechanical  or  medicinal  means.  This,  how- 
ever, can  only  be  done  when  there  is  sufficient  time  for  action  between  the 
beginning  of  the  aura  and  the  coming  on  of  the  unconsciousness.  When  the 
aura  begins  as  a  slowly-rising  sensation  in  one  of  the  extremities,  the  patient 
should  be  taught  instantly  to  grasp  with  the  hand  or  enciircle  with  a  tight 
band  previously  prepared  the  limb  above  the  point  of  attach  :  under  such 
circumstances  the  aura  will  often  be  unable  to  get  past  the  constriction.  If 
the  attack  manifest  itself  first  as  a  local  spasm,  such  as  the  crooking  of  a 
finger,  the  breaking  of  this  spasm  by  forcibly  stretching  the  part  should  be 
tried.  The  inhalation  of  nitrite  of  amyl  will,  in  many  cases  of  slow  aura,  if 
promptly  and  efficiently  performed,  arrest  the  fit.  The  patient  shoidd  always 
carry  ten  minims  of  the  nitrite  in  pearls  or  in  a  little  homoeopathic  vial  in  a 
])ocket  which  can  be  quickly  reached.  The  pearls  are  to  be  crushed  or  the  bot- 
tle emptied  on  the  handkerchief,  and  the  deep  inhalation  proceeded  with.  As 
soon  as  the  sensations  ordinarily  produced  by  the  nitrite  of  amyl  appear,  the 
inhalation  may  be  interrupted,  but  there  does  not  seem  to  be  any  danger  of 
injurious  effects,  since  no  case  of  serious  poisoning  by  the  nitrite  is  on  record. 

In  the  great  majority  of  epilepsies  the  aura  is  instantaneous  and  the  attack 
cannot  be  cut  short.  The  patient  should  be  placed  in  a  horizontal  position,  if 
he  has  not  already  fallen,  on  a  mattress  or  other  soft  body,  all  tight  bands  or 
clothing  be  loosened,  and  the  paroxysm  allowed  to  have  its  course;  cxcei)t 
that  it  is  well  to  thrust  something  soft  between  the  teeth,  so  as  to  prevent  the 
biting  of  the  tongue,  such  as  a  large  flat  piece  of  cork  or  India  rubber,  with  a 
string  tied  to  it,  so  that  if  it  should  by  any  means  get  into  the  back  of  the  throat 
it  may  be  withdrawn.  In  practice,  however,  it  is  rarely  possible  to  prevent 
the  biting:  of  the  tongue.  The  inhalation  of  ether  often  lessens  the  scvcritv  of 
the  convulsion,  and  seems  never  to  produce  any  injury.  I  have  seen  it  habit- 
ually practised  with  very  good  results,  and  it  has  the  great  advantage  of  satis- 
fving  the  natural  craving  of  nervous  mothers  to  be  doing  something.  Chloro- 
form is  more  promj)t  and  more  efficacious  than  ether,  but  its  use  is  attended 
with  ajjpreciable  danger.  Kxce|)t  when  in  jxtsition  of  peril,  force  should  not 
be  cm])lovcd  in  arresting  the  epilcptitr  convulsicm,  resistance  aggravating  ihc 
motor  disturbance.  After  the  attack  the  patient  should  b(^  allowed  to  sleep 
fpiietly  until  spontaneous  awaking  occurs. 

The  general  nianaixement  of  the  epileptic  case  should  be  both  hygienic  and 
medicinal.  I  ii  the  ivgulation  of  the  iiai)its  of  life  and  of  the  diet  of  the  patient 
moderation  in  all  things  is  ('specially  desirable.      SuHieient   sleep  and  moderate 


624  FUNCTIONAL    NERVOUS   DISEASES. 

exercise,  both  intellectual  and  physical,  should  he  strictly  enjoined.  In  my 
opinion  it  is  distinctly  a  mistake  in  the  case  of  children  or  young  adults  to 
attempt  to  do  away  with  all  efforts  at  intellectual  culture.  So  far  as  is  possible 
the  patient  should  conform  in  his  daily  life  to  the  habits  and  customs  of  the 
non-epileptic  individual,  excepting  that  in  all  things  he  should  avoid  excess. 
Especially  also  is  it  important  to  the  growing  epileptic  child  that  habits  of 
discipline  and  self-control  be  enforced  even  more  carefully  than  in  the  ordinary 
cliild.  Excessive  punishment  must  of  course  be  avoided,  but  by  light  punish- 
ments never  intermitted,  by  moral  means,  and  in  every  possible  way  the  moral 
nature  of  the  child  should  be  most  assiduously  cultivated.  The  fear  of  pub- 
licity, of  physical  injury  from  a  fall  during  the  fit,  and  a  false  sense  of  shame, 
all  tend  to  an  unnatural  withdrawal  of  the  patient  from  society,  from  business, 
and  other  pursuits.  So  long  as  it  is  possible  this  tendency  should  be  combated, 
and  it  is  much  wiser  to  take  even  the  risk  of  physical  injury  during  the  con- 
vulsion than  to  unnecessarily  seclude  the  patient.  Seclusion  means  of  necessity 
self-introspection,  and  self-introspection  helps  most  woefully  in  the  production 
of  mental  disorder. 

Tlie  diet  of  the  epileptic  should  be  chiefly,  but  not  altogether,  vegetable. 
Abstinence  from  meat,  which  has  been  advocated  by  some  authorities,  is  cer- 
tainly of  no  value,  and  flesh  may  be  allowed  twice  a  day  in  moderate  quantities 
without  any  evil  results  whatever.  Tobacco,  tea,  and  coffee  are  forbidden  by 
authorities,  but  I  do  not  myself  believe  their  use  in  small  quantities  does  any 
injury  in  the  adult. 

The  (juestion  as  to  the  propriety  of  marriage  is  frequently  put  to  the  med- 
ical practitioner.  The  answer  should  be  that  marriage  is  not  capable  of  doing 
the  jiatient  any  good  ;  that  if  care  be  exercised  to  avoid  any  excess  of  sexual 
indulgence  it  does  no  harm  to  the  patient ;  but  that  a  large  proportion  of  the 
progeny  of  such  marriage. will  suffer  from  epilepsy  or  other  grave  nervous 
disorder. 

Laxatives  and  other  drugs  may  be  used  in  epilepsy  whenever  required  for 
the  relief  of  perverted  local  function  ;  and  whilst  the  belief  frequently  expressed 
by  ])arents  that  the  attacks  are  of  gastro-intestinal  origin  is  rarely  true,  consti- 
pation certainly  tends  to  increase  the  frequency  of  the  convulsion. 

A  very  large  number  of  drugs  have  been  employed  from  time  to  time  as 
specific  antiepilejitics  :  amongst  these  alleged  specifics  valerian,  artemisia,  bella- 
donna, oxide  of  zinc,  sulphate  of  copper,  nitrate  of  silver,  may  all  be  mentioned 
as  absolutely  worthless.  Borax  has  of  recent  years  been  recommended  by  a 
number  of  practitioners,  but  in  my  experience  has  proven  itself  almost  worth- 
less. I  have  taken  a  wardful  of  epileptics,  and,  after  medicine  had  been  with- 
held for  weeks,  given  borax  in  as  large  a  dose  as  the  stomach  could  bear, 
without  any  apjjarent  effect  upon  the  aggregate  number  of  weekly  fits ;  and  I 
have  never  seen  an  individual  case  in  which  the  borax  treatment  attained  any 
brilliant  results.  The  only  remedies  which  I  have  seen  do  any  good  are  the 
bromides,  antipyrin,  antifebrin,  and  sulphonal.  My  experience  with  anti- 
febrin  and  sidphonal  has  not  been  sufficient  to  satisfy  me  as  to  their  value  as 


EPILEPSY.  G25 

contrasted  witli  antipvrin,  but  they  certainly  have  some  power,  and  probably 
may  at  times  be  used  with  advantage  as  a  substitute  to  antipyrin.  In  a  small 
proportion  of  cases  antipyrin  (ten  to  fifteen  grains  a  day)  has  a  remarkable 
effect  in  controlling  the  attacks,  and  I  have  seen  individuals  in  whom  it  acted 
more  happily  than  the  bromides.  I  know  of  no  way  of  clinically  determining, 
except  by  trial,  whether  antipyrin  will  suit  any  individual  case.  The  chief 
value  of  antipyrin,  sulphonal,  and  antifebrin  is,  however,  as  coadjutors  of 
the  bromides  rather  than  as  the  main  basis  of  the  treatment. 

Of  all  the  ren^edies  against  epilepsy,  the  bromides  are  the  most  service- 
able. Although  Albertoni  has  shown  by  direct  experiment  that  they  diminish 
decidedly  the  irritability  of  the  cerebral  cortex  in  the  motor  zone,  they  are 
palliative  rather  than  curative,  and  act  only  while  present  in  the  cortex.  They 
do  not  remove  the  tendency  to  epileptic  attacks,  but  antagonize  the  action  of 
such  tendency,  and  must  therefore  be  in  most  cases  administered  continuously 
for  many  years  after  the  occurrence  of  the  last  fit.  The  bromides  of  potassium, 
sodium,  lithium,  ammonium  have  been  chiefly  used.  Of  these  the  bromide 
of  potassium  has  been  most  employed.  I  have  no  reason  for  believing  in  its 
superiority  to  the  bromide  of  sodium.  The  bromide  of  lithium  has  yielded  iu 
my  hands  results  not  distinguishable  from  the  bromide  of  potassium,  but  is  so 
expensive  that  in  the  absence  of  any  advantageous  power  it  should  scarcely  be 
given.  The  bromide  of  ammonium,  I  feel  very  positive,  is  superior  to  the 
bromide  of  potassium  in  being  less  apt  to  produce  either  physical  or  nutritive 
depression.  It  is  capable  of  causing  all  the  ordinary  symptoms  of  bromism, 
but  these  symptoms  are  less  severe  than  those  produced  by  the  bromide  of 
potassium. 

"Whatever  bromide  is  selected,  it  should  at  first  be  given  in  ascending  doses 
until  the  occurrence  of  acne,  mental  depression,  foul  breath,  sonniolence,  or 
excessive  weakness  shows  that  bromism  has  been  produced  ;  unless,  indeed,  the 
paroxysms  are  absolutely  controlled  before  this  condition  is  reached.  Later 
through  the  case  the  effort  of  the  practitioner  should  be  to  keep  such  a  con- 
dition of  bromic  saturation  that  the  patient  will  be  continually  just  within  the 
limit  of  distinct  physiological  manifestation  of  the  (h'ug.  The  non-recurrence 
of  the  fits  for  a  month  or  several  years  gives  no  reason  for  the  withdrawal  of 
the  remedy.  The  effect  of  the  continuous  administration  of  the  bromide  upon 
the  general  health  seems  to  be  entirely  unimportant.  In  severe  cases  it  may 
be  necessary  to  maintain  a  distinct  mild  bromism,  but  this  is  alwavs  unfor- 
tunate,  and  to  be  avoided  if  possible.  The  tendency  of  the  bromides  to  pro- 
duce severe  skin  eruption  is  to  some  extent  counteracted  by  the  simultaneous 
use  of  arsenic.  Again,  the  combinaticm  of  antijjyrin  with  the  bromides  is 
most  effectual  in  its  results.  After  very  large  clinical  experience  I  am  sure 
that  a  mixture  of  bromide  of  ammonium,  antipyrin,  and  Fowler's  solution 
affords  the  best  combination  of  known  r(!medies  in  the  majority  of  epileptic 
cases.  As  the  bromides  act  i)y  accunitdati(»n  in  the  system,  it  is  not  necessary 
to  give  them  more  than  twice  in  the  twenty-four  hours — a  great  boon,  since 
the  frecpient  taking  of  medicine  is  often  exceedingly  irksome.     The  dose  of 

Vol.  I.— 40 


626  FUNCTIONAL    NERVOUS  DISEASES. 

the  bromide  of  ammonium  may  be  from  twenty  to  thirty  grains,  with  five  to 
seven  grains  of  antipyrin  and  two  to  three  minims  of  Fowler's  sohition.  I 
have  also  found  the  combination  of  bromide  of  ammonium  and  sulphonal 
efficacious.  It  will  probably  be  found  that  tiie  administration  of  the  mixture 
of  the  bromide  of  anmionium  and  antipyrin  cannot  be  kept  up  indefinitely; 
at  least  I  have  seen  cases  in  which  after  several  years  of  use  the  thermo-genitic 
functions  of  the  body  were  very  much  disturbed,  and  a  tendency  to  excessive 
coldness  of  the  extremities,  with  colliquative  sweating,  became  so  marked  that 
it  was  found  necessary  to  replace  the  antipyrin  by  sulphonal. 

In  rare  cases  of  epilepsy  the  epileptic  attacks  take  on  the  Jacksonian  form 
without  there  being  detectable  organic  lesions  of  the  brain.  The  question  as 
to  the  propriety  in  these  cases  of  surgical  removal  of  the  cortical  brain-centre 
cannot  as  yet  be  positively  answered.  A-priorl  reasoning  seems  to  me  to  lead 
to  the  probable  conclusion  that  such  removal  will  be  followed  by  secondary 
sclerosis,  and  that  any  benefit  which  may  be  obtained  must  be  temporary. 
Moreover,  the  clinical  results  so  far  obtained  do  not  seem  encouraging.  Never- 
theless, in  clear  cases,  with  the  consent  and  complete  understanding  of  the 
situation  by  those  persons  who  are  specially  interested,  the  surgeon  may  be 
justified  in  trephining  and  cutting  out  the  centres  believed  to  be  diseased. 

Convulsions. 

Convulsions  are  symptomatic  conditions  which  have  already  been  spoken 
of  in  various  places  in  this  work,  but  their  importance  necessitates  a  brief 
general  discussion  of  the  subject. 

The  Hysterical  ConvuMon  may  simulate  either  the  tetanic  or  the  epilepti- 
form, but  can  usually  be  distinguished  by  the  peculiar  disturbances  of  con- 
sciousness, and  by  its  partial  distribution,  and  by  the  persistent  rigidity  which 
attends  it. 

Tetanic  Convuhions  may  bo  due  to  strychnine  or  other  poisonings,  and  to 
tetanus,  traumatic  or  idiopathic.  The  diagnosis  is  to  be  made  out  through  the 
history  of  the  case  and  by  paying  attention  to  the  following  points :  In 
strychnine-poisoning  the  whole  muscular  system  is  invaded  almost  simul- 
taneously, and  the  muscles  of  the  jaw  are  the  last  to  be  aifected  and  the  first 
to  be  relaxed  ;  whilst  in  tetanus  the  symptoms  usually  commence  in  the  back 
and  neck  with  pain  and  stiffness,  and  the  jaw-aiuscles  are  the  earliest  to  set 
and  the  last  to  relax. 

In  the  case  of  Epileptiform  Convulsions  the  first  thing  that  the  practitioner 
has  to  make  out  is  whether  the  convulsion  is  one  of  a  series  or  not.  If  the 
convulsion  be  one  of  a  series,  it  is  probably  due  to  idiopathic  epilepsy  or 
organic  disease  of  the  brain,  but  may  be  the  outcome  of  uraemic,  alcoholic, 
plumbic,  or  other  persistent  poisoning,  and  in  rare  cases  has  its  origin  in 
repeated  cardiac  failure  or  a  persistent  peripheral  irritation.  It  does  not  seem 
necessary  to  discuss  here  the  diagnosis  between  these  affections,  as  they  have 
been  sufficiently  considered  elsewhere. 

An  isolated  convulsion  may,  of  course,  be  the  commencement  of  an  idio- 


ST.     Virus's   DANCE.  627 

pathic,  organic,  cardiac,  or  toxic  epilepsy,  but  is  usually  due  to  animal,  vege- 
table, or  mineral  poisoning  or  to  peripheral  irritation.  In  the  adult  it  is  most 
frequently  urseraic,  but  may  represent  another  poisoning.  In  yoiuig  children 
the  convulsion  is  often  a  prodromic  symptom  of  some  exanthcmatous  disease, 
but  still  more  frequently  is  it  the  outcome  of  an  irritation  caused  by  teething 
or  bv  indigestible  substances  in  the  gastro-intestinal  tract. 

The  nature  of  a  convulsion  ushering  in  scarlet  or  other  fever  can  usually 
be  recognized  by  the  peculiar  expression  of  illness  and  the  general  vital 
depression  which  attends  it,  and  by  the  disturbance  of  the  temperature,  aided 
in  some  cases  by  knowledge  of  exposure  to  contagion.  In  all  cases  of  acute 
convulsion  of  doubtful  etiology  the  gums  of  the  young  child  should  be  care- 
fully examined,  and  if  they  be  found  swollen  and  inflamed  should  be  lanced. 
It  should  also  be  a  uniform  practice  to  administer  as  rapidly  as  possible  an 
emetic  by  the  stomach,  or,  better  still,  to  give  a  hypodermic  injection  of  apo- 
morphine,  unless  some  distinct  cause  for  the  attack  other  than  gastric  irritation 
can  be  discovered,  as  gastric  convulsions  are  in  nowise  peculiar.  Moreover, 
the  vital  depression  and  fall  of  temperature  produced  in  a  susceptible  child 
bv  gastro-intestinal  irritation  (aided  perhaps  by  absorption  of  some  organic 
products,  probably  the  result  of  fermentative  changes,  as  after  eating  a  stale 
cream-puflP,  etc.)  may  closely  simulate  the  oncoming  of  a  systemic  fever. 

The  general  treatment  of  convulsions  in  children  may  be  summed  u])  to 
be — lancing  of  the  gums  if  necessary,  and  emptying  the  stomach  if  the  cause 
of  the  convulsion  be  obscure ;  the  administration  of  the  bromides  freely,  of 
chloral  very  carefully  ;  the  use  of  the  hot  bath,  and  careful  administration  of 
ether,  alcohol,  dio:italis,  and  strvchnine  when  the  circulation  fails.  I  have 
secured  recovery  in  cases  in  which  a  child  had  ceased  to  breathe,  and  was 
aj)parently  dead,  by  placing  it  in  the  hot  bath  and  using  artificial  respiration, 
the  emetics  which  had  failed  to  act  producing  free  vomiting  as  soon  as  the 
bodily  temperature  was  raised  and  the  accumulated  carbonic  acid  pumped  out 
of  the  system.  In  such  cases  the  hot  bath  acts  not  merely  as  a  relaxant,  but 
as  a  stimulant  to  the  circulation  and  restorative  to  the  failing  bodily  heat.  A 
little  mustard  in  the  bath  is  sometimes  useful. 

St.  Vitus's  Dance. 

Definition. — A  non-febrile  di.sease,  not  essentially  dependent  uj)on  demon- 
strable organic  affection  of  the  nervous  system  ;  usually  occurring  in  child- 
hood ;  characterized  by  choreic  movements  involving  the  whole  body,  with 
general  loss  of  nerve-tone  and  of  muscular  power. 

Synonyms. — Chorea  ;'  Chorea  minor;  Chorea  of  cliililhood. 

'  Tlie  names  of  St.  Vitus's  danoe,  tlie  dance  of  St.  .Joliii,  cliorca  minor  and  clioiva  major, 
and  rhorea  Kfrmanomm,  liave  been  used  witli  very  varied  meaninfrs  in  rctiard  to  their  sipnifi- 
eation.  It  appearw  that  tlic  I'lirvi:i:iii  liacehantes,  in  their  wiM  wor^liiji,  were  affected  with 
furious  nncontrolial)le  antomatic  movements,  accompanied  i)y  more  or  less  distnrliance  of  con- 
sciousness, and  it  is  certain  tliat  the  sect  of  the  Sulli,  in  I'ersia,  shortly  after  the  origin  of 
Mohammedanism,  were  accnstomed  in  theirHaered  ceremonies  to  pasH  into  a  condition  of  ra^inf,' 
excitement,  witli  fnrious  (hincin^,  convulsive  tremblings,  and  even  peneral  convulsions.     Altout 


628  FUNCTIONAL    NERVOUS   DISEASES. 

Etiolog-y. — Neuropathic  heredity  has  some  influence  in  predisposing  the 
child  to  St.  Vitus's  dance.  The  same  may  be  said  of  race,  the  disease  at 
least  being  more  rare  among  negroes  than  among  whites.  Any  habits  of  life 
which  lessen  the  robustness  of  the  nervous  system  are  also  effective ;  hence 
city  children  are  more  frequently  aifected  than  those  living  in  the  country. 
In  children  under  five  years  of  age  the  disease  is  rare,  though  it  may  occur  in 
infants.  About  four-fifths  of  the  cases  are  reported  as  having  been  in  children 
between  the  ages  of  five  and  fifteen.  Girls  are  much  more  frequently  affected 
than  bovs.  In  this  climate  chorea  occurs  more  frequently  in  the  spring 
months  after  the  exhaustion  of  the  hard  winter. 

So  large  a  proportion  of  the  sufferers  from  chorea  come  from  distinctly 
rheumatic  stock  or  have  had  rheumatism  themselves  before  the  chorea,  and  so 
frequently  does  chorea  seemingly  interchange  with  rheumatism,  that  some 
relationship  must  exist  between  the  two  diseases.  This  mysterious  relationship 
is  also  shown  by  the  frequency  of  organic  heart  disease,  and  even  of  acute 
endocarditis,  in  choreic  children. 

In  most  cases  no  distinct  exciting  cause  can  be  found  for  an  attack  of  chorea. 
Sometimes,  however,  the  affection  commences  abruptly  under  the  influence  of  a 
depressing  emotion,  especially  of  fright.  Chorea  is  prone  to  recur ;  not,  how- 
ever, because  one  attack  predisposes  to  another,  but  because  a  persistent,  funda- 
mental weakness  renders  the  nervous  system  liable  to  be  easily  thrown  off"  its 
balance  time  and  again.  The  attacks  may  recur  at  short  intervals  or  be  sepa- 
rated by  periods  of  years. 

Patholog-y. — Various  lesions  have  been  found  in  the  brain  and  in  the  spinal 
cord  after  death  from  St.  Vitus's  dance,  such  as  minute  cerebral  embolism, 
softening  of  the  spinal  cord,  interstitial  proliferation  of  nuclei,  and  hyperplasia 
of  the  spinal  neuroglia  with  serous  exudations  into  the  central  canal,  etc.  It 
must  be  remembered,  however,  that  chorea  may  be  caused  in  a  few  minutes  by 

the  year  1000  a  sectof  theSuffi  found  numerous  followers  and  imitators  throughout  Asia  Minor, 
Persia,  and  Egypt,  and  even  in  Greece.  In  Christian  lands  the  so-called  dance  of  St.  John  was 
already  at  the  time  of  the  Crusades  an  observed  custom ;  and  when  the  influence  of  the  Suffi 
spread  itself  l)y  the  returning  waves  of  the  Crusades,  the  epidemics  of  religious  excitement  and 
automatic  dancing  became  more  and  more  violent.  It  was  not  until  the  outbreak,  in  1418,  of  a 
fresh  epidemic  in  Strasburg  that  the  term  dance  of  St.  Veit  began  to  be  freely  applied  to  these 
religious  disorders — a  name  which  appears  to  have  had  its  origin  largely  in  the  fact  that  in 
these  later  epidemics  cliildrcn  were  especially  affected.  St.  Veit  was  a  boy  who,  born  in  the 
island  of  Sicily,  suffered  martyrdom  in  the  year  303  during  the  persecution  of  Diocletian,  and 
whose  body,  carried  hither  and  thither  for  a  considerable  length  of  time,  found  its  final  resting- 
place  in  ihe  cloister  of  Korvey. 

By  Paracelsus  these  ei)idemics  were  called  chorea  sancti  viti  and  chorea  lasciva.  The  disease 
of  childhood  now  known  as  St.  Vitus's  dance  has  no  connection  either  etiologically  or  in  its 
nature  with  these  epidemics,  but  modern  custom  enforces  the  application  of  the  name  to  it  as 
used  in  this  book.  V>y  many  German  writers  the  affection  of  childhood  is  known  as  chorea 
minor,  whilst  the  term  chorea  major,  or  chorea  germanorum,  is  used  to  express  affections  more 
or  less  closely  resembling  in  their  phenomena  those  of  the  epidemic  furies  of  the  Middle  Ages. 
By  some  German  writers  any  very  bad  case  of  ordinary  chorea  is  spoken  of  as  chorea  magna. 
Again,  the  term  chorea  major  or  chorea  germanorum  is  sometimes  used  as  a  name  for  the 
automatic  chorea  described  on  jjage  635. 


ST.     VITUS' S  DANCE.  629 

a  fright,  and  that  in  a  majority  of  cases  it  is  recovered  from  in  a  few  weeks. 
It  is  absurd  to  suppose  tiiat  serious  organic  change  of  the  nerve-centres  can  be 
present  in  tliese  cases.  Moreover,  competent  observers  have  failed  to  find  alter- 
ations in  the  nerve-centres  after  death  from  chorea.  A  large  number  of  observ- 
ers have,  however,  especially  noted  changes  in  the  spinal  cord,  the  ganglionic 
cells  appearing  shrivelled,  their  pi'otoplasm  granular,  their  nuclei  obscured,  and 
their  processes  indistinct  or  absent.  I  have  found  exactly  similar  lesions  in 
choreic  dogs,  and  have  noted  that  when  the  animals  were  killed  in  the  begin- 
ning of  an  attack  the  spinal  ganglionic  cells  showed  no  change :  a  little  later 
the  only  alterations  in  the  cells  were  the  very  frequent  absence  of  the  nuclei, 
the  failure  of  granulations  in  the  protoplasm,  the  loss  of  power  to  take  staining 
fluids,  and  rarely  the  occurrence  of  sharply-defined  vacuoles.  Then  the  ]>ro- 
cesses  began  to  drop  off;  and  finally  it  was  found  that  the  places  of  the  cells 
were  occupied  by  irregular,  globose,  crumpled-looking  masses,  without  sharp 
outline  and  taking  carmine  staining  very  faintly.  No  granulations,  no  nuclei, 
no  processes,  were  apparent.  Evidently  there  is  in  the  spinal  ganglionic  cell 
of  the  choreic  dog  an  altered  nutrition,  which  first  manifests  itself  solely  in  dis- 
order of  function  with  choreic  movements ;  after  a  time,  as  the  nutritive  pro- 
cess continues,  the  structure  of  the  cells  becomes  sufficiently  affected  for  change 
to  be  recognized,  and  in  fatal  cases  some  at  least  of  the  cells  have  undergone 
total  degeneration.  Similar  structural  changes  have  been  noted  in  the  gangli- 
onic brain-cells  of  choreic  dogs  and  cats.  In  the  choreic  child  during  life  the 
will,  the  intellect,  and  the  emotional  faculties  are  often  markedly  abnormal, 
whilst  after  death  structural  change  has  been  found  in  the  spinal  cell.  It  seems 
to  me  clear  that  the  pathology  of  St.  Vitus's  dance  is  an  alteration  in  the  nutri- 
tion of  the  ganglionic  structures  of  the  whole  cerebro-sj^inal  axis;  which  altered 
nutrition  may  fail  to  develop  structural  changes  sufficiently  great  to  be  recog- 
nized by  the  microscope,  or  may  go  on  until  it  produces  pronounced  structural 
lesions. 

Symptomatolog-y. — The  onset  may  be  sudden  or  gradual  in  its  develop- 
ment. The  attack  may  come  on  in  the  midst  of  aj)parent  health,  but  ordinarily 
it  is  preceded  by  languor,  irregular  action  of  the  gastro-intestinal  tract,  and  a 
pronounced  nervous  irritability.  The  motor  disturbance  may  be  first  indicated 
bv  a  peculiar  restlessness  of  the  child,  who  is  not  rarely  punished  for  fidgeting. 
The  true  choreic  movements  usually  appear  first  in  the  fingers,  afterward  in  the 
face,  and  then  spread  until  they  involve  the  whole  body. 

In  a  large  proportion  of  cases  very  often  the  two  sides  of  the  body  are  not 
equallv  affected,  and  sometimes  the  symptoms  arc  limited  to  one  side  (liemi- 
chorea),  or  in  rare  cases  are  almost  confined  to  one  extremity.  A  distinct 
increase  of  electric  irritability  has  been  notc<l  in  Ixitli  nerve  and  nuiscle  of  the 
affected  side,  and  even  (pialitative  changes  have  been  described,  \\  being  stated 
that  the  closure  contracture  at  the  negative  pole  may  become  equal  to  the  open- 
ing contracture.  Sensibility  is  usually  not  infiueneed,  except  (Iiat  lender  points 
over  nerve-trunks  are  said  often  to  be  deinonslrable.  Iflliere  l»e  distinct  pain 
present,  rheumatic  or  organic  complications  shoidd  be  suspected.     The  jjupils 


630  FUNCTIONAL    NERVOUS   DISEASES. 

are  usually  somewhat  dilated  and  react  slowly  to  light ;  very  rarely  they  are 
unequal.  Antemia  is  frequent.  When  marked  fever  occurs,  rheumatism,  endo- 
carditis, or  other  complication  probably  exists  ;  but  slight  elevation  of  temper- 
ature, apparently  of  nervous  origin,  is  sometimes  present. 

In  severe  attacks  of  St.  Vitus's  dance  the  arras  are  in  almost  constant 
movement,  the  fingers  opening  and  closing,  the  wrists  flexing  and  extending, 
and  the  elbow-joints  in  almost  incessant  activity,  so  that  every  imaginable 
position  of  the  hand  and  arm  is  rapidly  taken  and  lost.  During  the  violence 
of  the  disease  it  is  impossible  for  the  child  to  control  the  movements  of  the 
arm  sufficiently  to  dress  or  feed  himself  or  to  perform  any  act  requiring  pre- 
cision of  motion.  At  this  time  the  legs  are  similarly  affected,  so  that  walking 
is  graduallv  interfered  with  or  may  be  rendered  impossible.  The  steps  are 
irregular,  jerking,  often  with  lateral  movements,  now  rapid,  now  slow,  and 
if  progression  occur  at  all  it  is  zigzag  and  uncertain.  The  face  and  head  are 
no  less  affected :  there  is  a  constant,  ever-changing  distortion  of  the  counte- 
nance, giving  rise  to  fleeting  expressions  of  sadness,  terror,  grief,  rage,  etc., 
and  to  grimaces  innumerable.  The  mouth  is  opened  and  shut,  the  corners 
jerking  up  and  down  ;  the  tongue  is  protruded  or  sometimes  moved  rapidly 
in  the  mouth,  so  as  to  produce  a  peculiar  clacking  sound.  Articulation  grows 
indistinct,  the  child  speaks  irregularly  and  badly,  perhaps  only  in  monosyl- 
lablesj  and  finally  the  voice  may  be  converted  into  a  succession  of  irregular, 
unintelligible  sounds.  In  very  bad  cases  mastication  becomes  almost  impos- 
sible, and  even  the  muscles  of  deglutition  are  involved,  so  that  the  child  is 
unable  to  swallow  at  the  proper  moment,  and  the  food  is  spluttered  and  spilled 
about.  The  head  itself  is  moved  rapidly  to  and  fro,  backward  and  forward, 
sometimes  laterally,  sometimes  in  perpetual  rotation.  In  the  most  violent  cases 
all  the  muscles  of  the  body  are  in  a  condition  of  furious  action.  The  rolling, 
twisting  movement  of  the  trunk  and  the  perpetual  beatings  and  thrashings  of 
the  extremities  render  it  almost  impossible  for  the  patient  to  lie  in  bed  unless 
fastened  down,  and  the  utmost  care  is  necessary  to  prevent  severe  bruises  and 
excoriations  of  the  skin. 

The  respiratory  muscles  are  the  last  to  be  affected,  but  cases  have  been 
reported  in  which  hiccough,  crowing  inspiration,  irregular  respiratory  rhythm, 
and  other  evidences  of  choreic  action  of  the  respiratory  muscles  were  abun- 
dantly present.  The  choreic  movements  cease  at  night,  or  at  least  during  sleep, 
but  in  the  most  severe  cases  by  keeping  the  patient  awake  they  produce  an 
insonniia  which  constitutes  an  additional  factor  in  the  rapid  wearing  out  of  the 
strength  and  the  bringing  about  of  a  fatal  result.  That  the  brain-cortex  does 
not  entirely  escape  is  shown  by  the  peculiar  nervous  irritability  which  forms 
an  almost  essential  symptom  of  the  disease.  The  general  intelligence  is  ordi- 
narily well  preserved,  but  there  can  often  be  noted  a  temporary  weakness  of 
memory,  and  the  loss  of  the  power  of  fixing  the  attention  upon  any  one  sub- 
ject for  a  length  of  time  is  usually  very  decided. 

Hallucinations  are  very  rare,  and  usually  indicate  that  a  chorea  is  hysteri- 
cal.    They  may,  however,  occur  in  typical  St.  Vitus's  dance.     In  fatal  cases 


ST.     VITUS' S  DANCE.  631 

the  mental  disturbances  are  very  pronounced  ;  there  may  be  even  an  acute 
dementia  :  sometimes  the  patient  is  seized  with  maniacal  delirium,  which  is 
always  of  exceedingly  serious  imj)ort. 

The  muscles  of  organic  life  may  participate  in  the  choreic  dibturbance. 
This  is  especially  true  of  the  heart.  Chronic  valvular  lesions  are  frequent 
among  choreic  patients,  and  an  acute  endocarditis  occasionally  occurs  during 
an  attack  of  St.  A^itus's  dance;  but  cases  are  not  rare  in  which  mitral  or  even 
aortic  murmurs  are  heard  during  an  attack  which  are  not  due  to  any  organic 
lesion  of  the  heart  and  are  not  hanuic  in  their  origin.  This  is  shown  by  the 
fact  that  these  murmurs  occur  when  there  is  no  anaemia,  that  they  vary  from 
day  to  day  and  from  hour  to  hour,  and  at  times  may  be  absent,  and  that  when 
the  child  recovers  from  the  chorea  the  murmur  disappears  entirely. 

Further,  fatal  cases  have  been  reported  in  Avhich  no  valvuhu-  lesion  was 
found  in  the  autopsy,  although  marked  cardiac  murmurs  had  existed  during 
life.^  The  most  rational  explanation  of  these  murmurs  is  that  they  are  due 
to  the  irregular  contractions  of  the  chordae  tendinae  preventing  the  jM-oper 
closure  of  the  valves.  It  is  the  duty  of  the  practitioner  always  to  auscult  the 
heart  of  the  choreic  child,  and  if  murmurs  be  present  to  decide,  if  possible, 
their  significance.  If  the  history  of  a  previous  endocarditis  or  of  previous 
chronic  valvular  lesions  can  be  obtained,  the  probabilities  are  always  that  the 
murmur  is  due  to  an  old  lesion.  The  absence  of  such  history  is,  unfortunately, 
no  proof  of  the  previous  non-existence  of  cardiac  disease.  Supposing  that  the 
murmur  is  recent,  it  is  often  a  very  difficult  matter  to  decide  whether  it  is 
neurotic  or  inflammatory.  The  neurotic  murmur  rarely,  if  ever,  manifests 
itself  in  irregularity  of  the  pulse;  it  is  not  associated  with  cardiac  pain  nor 
with  elevation  of  the  general  temperature.  If  these  exist,  the  diagnosis  of 
acute  endocarditis  may  be  considered  made  out.  The  presence  of  even  one  of 
these  symptoms  should  lead  the  practitioner  to  treat  the  case  as  one  of  endo- 
carditis. 

The  course  even  of  so-called  acute  chorea  is  always  slow  and  almost 
indefinite  in  its  duration  ;  rarely  is  recovery  complete  under  five  weeks.  Tiie 
ordinary  result  is  a  complete  cure,  but  in  rare  cases  permanent  loss  of  power 
in  muscle  or  mind  remains,  evidently  because  of  organic  changes  in  the  nerve- 
centres  which  have  been  brought  about  by  the  chorea.  Death  is  exceedingly 
rare. 

Diagnosis. — Reflex  chorea  often  so  exactly  resembles  St.  Vitus's  dance 
that  its  true  nature  can  only  be  made  out  by  the  detection  of  the  point  of  irri- 
tation. Especially  are  eye-strain  and  nasal  difficulties  apt  to  cause  in  child- 
hood persistent  chorea,  and  it  is  therefore  essential  in  every  case  which  resists 
treatment  to  thoroughly  examine  these  organs.  The  teeth  and  the  sexual 
organs  shoidd  also  be  carefully  lool<ed  at:  adiicrcnt  prepuce  willi  irritation 
of  the  ghuids  in  the  male,  and  a  similar  condition  t)f  tlu;  clitoris  in  the  female, 
oft(!n  ])roduc(!  a  form  of  (probably)  chorea.  Hysterical  chorea  may  closely 
nimulate  ordinary  St.  Vitus's  dance.  The  nature  of  sudi  a  case  is  to  be  recog- 
'  Revue  menu,  dm  M<il<iilie«  de  V Enfanre,  1884,  ii.  421. 


632 


FUXCTIONAL    NERVOUS  DISEASES. 


nized  by  the  existence  of  marked  concomitant  symptoms  of  hysteria,  and  by 
occasional  persistent  rigidity  in  the  affected  muscles. 

The  true  choreic  neurosis  is  closely  allied  to  the  hysterical  neurosis,  and  it 
is  often  equally  correct  to  speak  of  a  case  as  one  of  hysterical  chorea  or  of 
choreic  hysteria.  The  choreic  movements  of  hysteria  are  also  more  apt  to  be 
rhythmical  than  in  St.  Yitus's  dance.     (See  Convulsive  Chorea,  p.  633.) 

Treatment. — The  treatment  of  St.  Vitus's  dance  should  be  both  hygienic 
and  medicinal.  As  the  underlying  condition  is  one  of  lowered  nerve-tone  and 
nerve-nutrition,  rest,  fresh  air,  exercise,  careful  feeding,  and  tonics  must  be 
employed  in  order  to  increase  nutritive  activity.  The  judgment  of  the  prac- 
titioner must  decide  in  each  individual  case  how  much  of  the  time  the  child 
shall  spend  in  the  bed  and  how  much  in  the  open  air.  The  general  error  is, 
I  think,  in  allowing  feeble  children  to  take  more  exercise  than  their  strength 
permits,  and  certainly  indolence  rather  than  activity  must  usually  at  first  be 
urged  upon  the  choreic.  Many  hours  a  day  ought  ordinarily  to  be  spent  on  the 
bed,  while  in  the  severe  cases  a  rest-cure  treatment  may  be  necessary.  At  the* 
same  time  the  child  should  be  kept  in  the  open  air  as  much  as  possible.  When 
the  weather  permits  swinging  in  a  hammock  or  lying  upon  a  couch  the  patient 
may  at  the  same  time  obtain  rest  and  fresh  air.  The  food  should  be  nutritious, 
but  not  stimulating,  thoroughly  digestible,  and  given  in  as  large  quantities  as 
the  alimentary  canal  will  assimilate — milk  and  farinaceous  articles,  with  a  very 
restricted  use  of  meat  and  of  sugar.  Bitter  tonics  and  alcohol  in  small  quan- 
tities may  be  administered  to  increase  the  activity  of  the  digestive  organs, 
\vhilst  cod-liver  oil  and  iron,  if  well  borne,  may  be  employed  as  nutrients. 
At  one  time  purgatives  were  much  used,  and  they  are  certainly  valuable  if 
given  only  in  such  doses  as  will  keep  the  digestive  tract  thoroughly  cleaned 
out  and  stimulated.  The  bitter  vegetable  purgatives,  I  think,  are  more  useful 
than  salines. 

The  special  medicinal  treatment  of  chorea  is  naturally  divided  into  the 
palliative  and  the  curative.  The  palliative  treatment  consists  in  the  use  of 
drugs  which  depress  motor  activity.  It  is  important  to  remember  that  these 
remedies  have  no  directly  curative  influence ;  that  they  are  rarely  to  be 
employed  except  in  very  severe  cases ;  and  that  in  severe  cases  they  accom- 
l)lish  permanent  good  only  by  procuring  rest  and  sleep.  The  bromides  are 
not  very  effective,  are  distinctly  depressing  to  the  nutrition  of  the  nervous 
system,  and  are  only  to  be  used  under  peculiar  circumstances.  Chloral  will, 
for  the  time  being,  quiet  almost  any  choreic  movements ;  especially  is  it  active 
when  combined  with  morphine ;  and  in  all  cases  of  chorea  threatening  life  a 
combination  of  these  drugs,  in  the  proportion  of  ten  grains  of  chloral  to  one- 
eighth  of  a  grain  of  morphine,  should  be  given  at  night  in  such  amounts  as 
may  be  necessary  to  procure  quiet  sleep. 

There  are  two  remedies  which  seem  to  have  a  specific  action  in  chorea. 
Arsenic  is  extraordinarily  eflTective :  it  should  always  be  given  by  itself,  so 
that  its  dose  can  be  altered  independently  of  other  remedies,  and  must  be 
administered  in  ascending  doses  up  to  the  limit  of  toxic  action.     A  child  five 


REFLEX   CHOBEA.—COXVCLSIVE    CHOREAS.  633 

years  old  may  commence  with  three  drops  of  Fowler's  solution,  given  after 
meals  in  milk,  the  dose  being  increased  every  third  day  one  drop  until  distinct 
puffiness  of  the  face  or  gastro-intestinal  disturbance  is  produced,  when  the 
medicine  may  be  temporarily  withdrawn  until  its  effects  have  subsided.  Cimi- 
cifuga  sometimes  succeeds  after  the  failure  of  arsenic :  a  fresldy-prepared  fluid 
extract,  having  a  strong  odor  of  the  drug,  should  be  given  in  increasing  doses 
until  it  causes  headache  or  vertigo.  Thirtv  minims  mav  be  the  commencinsf 
dose  for  a  child  nine  years  old. 

After  a  chorea  has  been  subdued  the  habits  of  life  of  the  child  should  be 
arranged  with  the  greatest  care  in  order  to  change,  if  possible,  the  inherent 
feebleness  of  nerve-constitution  which  is  usually  the  basis  of  chorea. 

Reflex  Chorea. 

Definition. — Local  or  general  chorea,  due  to  some  peripheral  irritation. 

Local,  unihitcral,  widespread,  or  generalized  choreic  movements  may,  under 
conditions  of  the  nervous  system  not  M'cII  undei-stood,  arise  from  local  irrita- 
tions. In  rare  cases  the  sym])toms  may  closely  simulate  those  of  St.  Vitus's 
dance.  Intestinal  parasites,  diseased  teeth,  neuromatous  tumors,  nasal  deform- 
ities— with  their  consequent  disease  of  the  mucous  membrane — and  other  irri- 
tations have  in  numerous  cases  given  rise  to  choreic  disturbances,  which  have 
subsided  rapidly  or  at  once  ujion  the  removal  of  the  ])oint  of  irritation. 

Chorea  of  Pregnancy  seems  to  be  produced  by  the  conjoint  influence  of  a 
predisposition  to  chorea,  inlierited  or  acquired  inanition  of  the  nerve-system 
incident  to  the  hydrsemic  state  of  the  blood  during  pregnancy,  and  various 
potential  irritations,  esjiecially  in  connection  with  the  sexual  organs.  It  is  a 
very  serious  affection,  in  which  the  movements  are  often  so  excessively  violent 
and  incessant  that  they  deprive  the  sufferer  of  sleep,  and  materially  aid  in  tlie 
I)r(jduction  of  a  rapidly  progressive  exhaustion  which  not  rarely  ends  in 
death. 

After  the  removal  of  the  irritation  the  treatment  of  reflex  chorea  is  the 
same  as  that  of  St.  Vitus's  dance,  excej)ting  that  much  more  is  to  be  expected 
from  motor  sedatives — i.  e.  palh'ative  remedies.  In  the  cliorea  of  pregnancy 
no  time  should  be  lost  in  bringing  the  patient  as  rapidly  as  possible  under  the 
influence  of  chloral  and  opium,  whilst  the  strength  is  maintained  by  moderate 
stimulation  and  high  feeding  uj)  to  the  point  at  which  the  digestive  system 
refuses  to  do  more  work.  Wiien  these  measures  fail  the  general  consensus  of 
the  best  obstetrical  opinion  is  in  favor  of  producing  abortion  before  the  patient's 
strength  is  too  much  exhausted. 

Convulsive  Choreas. 

Definition. — Paroxysmal  alVcclioiis  in  which  violent  choreic  movements 
occur,  which  are  not  distinctly  i)urposive,  or  at  least  do  not  simulate  compli- 
cated })urposive  acts,  and  arc  ndt  ntlcmlcd  wllli  loss  of  consciousness. 

Under  the  ])resent  heading  arc  included  groups  of  cases  in  which  the  symp- 
toms, though  more  or  less  similar,  liavc  (lilfcrciit  origin.      \'^arious  names  have 


634  FUNCTIONAL   NERVOUS   DISEASES. 

been  given  to  these  cases — local  chorea,  habit  chorea,  convulsive  tic,  etc.  Most 
of  the  cases  are  arranged  in  one  of  three  groups. 

Group  First:  Hysterical  Chorea. — Almost  any  form  of  movement 
may  occur  in  hysteria.  When  the  whole  body  or  a  portion  of  it  is  the  seat  of 
more  or  less  rapidly  repeated  clonic,  peculiarly  brusque  spasms,  resembling 
those  produced  by  an  electric  shock,  the  case  is  sometimes  spoken  of  as  electric 
chorea.  The  choreic  movements  of  hysteria  are  apt  to  be  very  rapid  and  more 
or  less  rhythmical.  They  frequently  attack  extremities  distorted  by  hysterical 
contractures.  Thus  in  a  leg  violently  flexed  by  contractures  I  have  seen  the 
knees  vibrate  laterally  over  a  considerable  arc  at  the  rate  of  one  hundred  and 
twenty  times  a  minute.  By  tracing  a  series  of  cases  it  will  be  seen  that  dis- 
orderly choreic  movements  insensibly  pass  into  vibrations,  and  these  into  true 
rhythmic  spasms.  Rhythmic  spasms  may  affect  any  pcjrtion  of  the  body. 
The  limbs,  normal  or  distorted  by  contractures,  may  be  agitated  with  regular 
movements.  The  face  may  be  attacked  rhythmically,  and  facial  grimaces, 
with  or  without  the  consentaneous  thrusting  forward  of  the  tongue,  occur. 
Occasionally  the  muscles  of  the  larynx  and  of"  respiration  are  also  affected,  so 
that  each  spasm  is  accompanied  by  a  quick,  strange  utterance.  This  rhythmic 
chorea  again  passes  by  insensible  degrees  into  the  purposive  movements  of 
hysteria. 

Group  Second:  Choreic  Tic. — In  this  form  the  choreic  movements  may 
simulate  single  purposive  acts.  It  is  probable  that  in  many  of  these  cases 
the  movements  have  originated  during  childhood,  at  a  time  when  they  might 
have  been  controlled  by  a  strong  effort  of  the  will,  but,  this  effort  not  having 
been  put  forth,  the  bad  habit  has  grown  in  a  neurotic  temperament  into  a  fixed 
neurosis  entirely  beyond  control  of  the  will ;  hence  the  term  "  habit  chorea." 
At  first  perhaps  remedial  by  hygienic  and  moral  treatment,  aided  by  the  use 
of  arsenic,  they  at  last  are  not  affected  by  any  treatment.  On  the  other  hand, 
some  of  these  cases  of  tic  are  from  the  onset  uncontrollable.  The  tic  or  spasm 
may  involve  a  single  nerve-distribution  or  a  widespread  area  ;  may  be  irreg- 
ular, having  no  apparent  relation  with  life  ;  or  may  continue  the  form  of  a 
])urposive  act  in  which  perchance  it  has  had  its  start.  A  brow  may  be  lifted 
at  intervals,  an  eye  winlced,  a  jaw  dragged  forward,  a  shoulder  shrugged,  a 
trick  of  gesture  incessantly  repeated,  even  a  cough  or  a  snuffle  perpetually 
indulged  in.  When  the  paroxysm  is  widespread  and  accompanied  by  a  dia- 
])hragmatic  contraction,  which  by  forcibly  expelling  the  breath  produces  some 
bizarre  sound,  the  case  may  assume  the  appearance  of  an  automatic  chorea,  but 
is  essentially  different  from  those  cases  in  which  the  movements  are  directed 
toward  an  end  and  are  the  outcome  of  a  dominating  impulse. 

The  treatment  of  the  cases  usually  ends  in  disappointment,  and  must  be 
chiefly  hygienic  and  symptomatic.  It  is  probable  that  in  cases  which  fail  to 
yield  some  minute  change  has  occurred  in  the  nerve-centres. 

Group  Third:  Cases  in  which  the  Choreic  Movements  are  Due 
TO  Various  Organic  Diseases  of  the  Nervous  Centres. — Under  this 
heading  also  may  be  included  the  so-called  senile  chorea  and  the  chorea  of 


? 


AUTOMATIC    CHOREA.  635 

insanity,  althougli  these  affections  are  usual ly  more  widespread  and  more 
closely  resemble  in  their  symptomatology  the  chorea  of  chiUlhood  than  do 
most  spasmodic  choreas. 

Most  of  these  organic  choreas  are  hopeless,  many  of  them  undoubtedly 
being  connected  with  changes  in  the  cerebral  cortex.  I  have  seen,  however, 
a  senile  chorea  unexpectedly  get  well,  the  patient  at  the  same  time  recovering 
mental  health. 

Automatic  Chorea. 

Definition. — An  affection  in  which  paroxysms  of  apparently  purposive 
actions  occur  independently  of  the  will  of  the  person,  as  the  result  of  an 
impulse  which  arises  spontaneously  in  the  individual  or  which  occurs  in 
response  to  something  received  from  without  the  individual.  ^ 

The  above  definition  covers  two  series  of  cases  :  first,  those  cases  in  which 
the  paroxysms  arise  spontaneously,  the  chorea  major  or  chorea  germanorum  of 
some  authors,  also  the  salaam  convulsions  (tic  salaam) ;  second,  those  cases  in 
which  the  paroxysms  are  the  result  of  some  external  irritation,  constituting 
the  affection  which  has  been  described  in  America  as  the  "jumpers,"  in  South- 
ern Asia  under  the  Malav  name  of  latah,  in  Eastern  Siberia  as  mirvachit,  in 
France  as  tic^  convulsif  (in  part)  and  as  Gillis  de  la  Tourette's  disease. 

Symptomatolog-y. — In  chorea  major,  or  chorea  germanorum,  the  outbreak 
is  usually  preceded  by  prodromes,  such  as  melancholy,  apathy,  feeling  of 
nausea,  malaise,  cramps  or  tonic  convulsions,  disturbances  of  the  circulation, 
palpitations,  etc.  The  paroxysms  usually  come  on  with  a  general  excitement, 
which  perhaps  ought  to  be  considered  as  a  form  of  aura.  During  the  parox- 
ysms the  affected  person  dances,  sings,  springs  from  the  ground,  rolls  himself 
from  side  to  side,  hammers  violently  with  the  hands,  stamps  with  the  feet,  or 
in  a  fury  of  motor  excitement  whirls  with  mad  raj)idity  until,  completely 
exhausted,  he  falls  to  the  ground.  The  excitement  is  not  confined  to  the 
motor  sphere :  songs  are  sung,  affairs  recited,  foreign  tongues  spoken,  in  a 
manner  entirely  beyond  the  normal  power  of  the  individual ;  events,  lan- 
guages, poetical  quotations,  which  seemingly  never  have  been  engraved  upon 
the  memory,  are  recounted  or  recited  in  eloquent  or  incoherent  ravings.  In 
the  height  of  the  attack  consciousness  is  usually  lost,  but  sometimes  it  is  in  a 
measure  preserved,  especially  in  the  sporadic  cases.  As  an  instance  of  the 
sporadic  variety  may  be  mentioned  a  case  re])orted  by  Robert  Watt,  in  which 
a  girl  ten  years  old  turned  herself  round  and  round  in  paroxysms;  later,  she 
had  attacks  in  which  she  would  roll  from  end  to  end  of  the  bed  violently 
backward  and  forward,  then,  lying  upon  her  back,  her  f(>et  and  head  would 
be  forcibly  jerked  together  ten  or  twelve  times  a  niiiiute.  A  single  paroxysm 
of  these  movements  often  lasted  fourteen  hours  a  diiy. 

Some  cases  like  those  described  in  the  ])reccding  paragrajih  have  probably 
been  instances  of  epileptic  automatism,  whilst  others  h:i\'e  been  fi^rms  of  hys- 

'  Many  of  the  cases  described  as  convulsive  tic  l)y  French  and  other  .nithors  represent  spas- 
modic diorea.  (See  page  0'.\A.)  Fnrllicr,  as  automatic  chorea  was  well  dcscrihod  before  the 
first  article  of  Toiirette,  there  is  no  jiistilication  for  attaching  his  name  to  the  disciise. 


636  FUNCTIONAL    NERVOUS   DISEASES. 

teria,  allied  to  the  hysterical  religious  epidemics  of  the  Middle  Ages  and  to 
the  performances  which  have  been  frequently  witnessed  at  revival  scenes  dur- 
ing camp-meetings  in  the  United  States  and  among  the  Howling  Dervishes 
of  Mohammedan  countries. 

Of  diiferent  character  are  probably  the  so-called  salaam  convulsions  of 
children,  in  which  the  paroxysms  recur  several  times  a  day,  last  from  a  few 
seconds  to  some  minutes,  and  consist  of  a  bowing  forward  of  the  head  and  body 
])erhaps  as  many  as  two  hundred  times.  Allied  to  these  cases  is  that  of  a  man 
who  formerly  lived  in  this  city,  who  when  seized  with  the  paroxysms  would 
spring  np,  rush  to  a  table,  and  jam  his  hat  down  upon  his  head  several  times, 
uttering  at  the  same  time  certain  words. 

^  The  essential  feature  of  latah  is  an  extreme  excitability  of  the  patient,  which 
causes  him,  upon  the  least  abrupt  excitation,  such  as  would  be  produced  by 
slapping  him  on  the  shoulder,  hallooing  at  him,  slamming  a  door,  etc.,  to  jump 
or  perform  other  violent  disorderly  acts,  conjoined  svith  a  condition  of  the 
cerebral  nervous  system  which  necessitates  a  repetition  of  voices  or  sounds 
{echolalgia)  or  the  ejaculation  of  some  Avord,  usually  obscene  {coprolalgid).  In 
some  cases  the  impulse  of  imitation  is  so  great  as  to  force  the  victim  to  repeat 
not  only  the  spoken  word,  but  also  any  act  done  by  a  bystander.  Very  fre- 
quently the  sudden  nervous  excitement  is  accompanied  by  an  excessive  emotion, 
especially  of  fear,  although  such  emotion  may  be  entirely  foreign  to  the  ordi- 
nary nature  of  the  individual.  The  disease  appears  to  be  hereditary.  It  often 
affects  various  members  of  several  generations  of  one  family. 

This  affection  was  described  by  Dr.  George  M.  Beard  in  1880,  Avho  found 
in  the  so-called  "jumping  Frenchman"  of  Maine  that  the  hearing  of  a  sudden 
voice  or  noise  caused  a  repetition  of  the  words  or  sounds,  with  the  performance 
of  strange  antics,  whilst  a  loud  command  was  always  obeyed,  often  with  a  cry 
of  alarm  not  unlike  that  of  hysteria  or  epilepsy.  Two  "jumpers"  standing 
near  each  other  when  commanded  to  strike  each  other  did  so  with  zeal.  Dr. 
Beard  tested  the  echo-speaking  or  repetition  by  reading  portions  of  Latin  and 
Greek,  when  the  untutored  "jumper"  repeated  the  sounds  of  the  words  as 
they  came  to  him  in  a  quick,  sharp  voice,  at  the  same  time  jumping  or  making 
some  bizarre  motion. 

M.  (3'Brien  makes  four  classes  of  cases,  as  he  has  seen  them  in  Southern 
Asia  : 

Class  first,  comprising  those  individuals  in  whom  an  unexpected  noise  pro- 
duces great  alarm,  with  an  irresistible  impulse  to  rush  upon  the  nearest  object, 
and  at  the  same  time  forces  an  exclamation  Avhich  is  always  obscene. 

Class  second,  comprising  those  persons  in  whom  certain  words  when  sud- 
denly pronounced  will  produce  an  excessive  paroxysm  of  sudden  terror.  Thus, 
in  an  individual  noted  for  his  courage  and  who  faced  the  living  alligator  with- 
out a  sign  of  fear,  the  sudden  pronouncing  of  the  word  "  buaya  "  (Malay  for 
"alligator")  produced  a  paroxysm  of  overpowering  terror. 

In  class  third  the  individuals  imitate  the  words,  gestures,  or  sayings  of  those 
in  their  neighborhood. 


Jf, 


HEREDITARY    CHOREA.  637 

In  i\iQ  Jourtli  cla.ss  the  individuals  become  completely  abandoned  to  the  will 
of  some  other  person,  performing  every  act,  however  outre  or  improper,  which 
they  are  commanded  to  do  by  such  individual — standing  on  their  heads,  attack- 
ing a  spectator,  etc.  In  these  cases  the  person  who  suffers  from  latali  recognizes 
his  enslavement  and  is  greatly  depressed  thereby,  but  is  unable  to  prevent  it. 

Patholog-y. — It  seems  to  me  that  those  cases  of  chorea  major  which  are 
neither  hysterical  nor  epileptic,  and  all  cases  of  latah,  are  more  closely  related 
to  reasoning  insanity  than  to  spasmodic  disorders,  the  paroxysms  of  movement 
being  ])roduced  by  morbid  impulses  similar  to  those  which  occur  in  various 
neuropathic  insanities.  (See  page  578.)  It  is  probable  that  the  subject  of 
latah  is  under  the  influence  of  a  dominating  idea  which  compels  him  to  obey 
or  to  imitate  as  the  case  may  be.  I  have  seen  a  feeble  neuropathic  child  develop 
such  a  mental  condition  that,  under  command,  the  most  bizarre  positions  were 
taken  and  maintained  for  an  extraordinary  length  of  time,  giving  an  appear- 
ance easily  mistaken  for  catalepsy.  The  relations  of  this  mental  state  to  certain 
stages  of  hypnotism  are  very  evident. 

Treatment. — There  is  no  reason  for  believing  that  any  specific  medicinal 
treatment  is  of  avail  in  the  affection  now  under  consideration. 

Hereditary  Chorea. 

Definition. — A  peculiar  hereditary  affection,  characterized  by  the  j)re.senco 
of  general  choreic  movements,  usually  associated  with  other  evidences  of  dis- 
turbed innervation,  and  probably  due  to  a  developmental  organic  affection  of 
the  nerve-centres. 

Synonym. — Huntington's  chorea. 

Etiology. — So  far  as  our  present  knowledge  goes,  this  affection  always 
depends  for  its  existence  upon  direct  heredity.  It  is  commonly  a.sserted  that, 
if  the  di.sease  fail  to  ap})ear  in  one  generation,  all  succeeding  generations 
remain  free,  but  clinical  experience  shows  that  this  is  not  invariably  the  case. 
It  is  not  known  that  exciting  causes  play  any  important  role  in  the  develop- 
ment of  the  disease. 

Pathology. — Hereditary  chorea  aj^pears  to  be  very  closely  allied  to  hered- 
itary ataxia,  and,  like  the  latter  disorder,  probably  depends  upon  some  devel- 
opmental departure  from  the  norm  in  the  nervous  .system,  although  at  present 
we  have  no  positive  knowledge  as  to  this  point.  In  the  spinal  cord  of  a 
patient  who  had  been  affected  with  this  di.sorder  Dr.  Wharton  Sinkler  found 
in  the  antero-lateral  columns  of  the  cord  an  abnormal  amount  of  connective 
tis.sue,  thickening  of  the  walls  of  its  blood-vessels,  and  absence  of  many  of  the 
axis-cvlinders.     The  central  canal  was  occupied  by  a  mass  of  nuclear  tissue. 

Symptomatology. — Hereditary  chorea  u.sually  develops  in  middle  life, 
although  in  simie  cases  it  has  a])peared  at  or  even  before  |)uberly.  The  choreic 
movements  resemble  those  of  St.  Vitu.s's  dance,  but  .nc  more  c(m.stant,  more 
rhythmical,  and  less  under  the  control  of  tlic  will.  While  standing  or  sitting 
the  j)atient  is  continually  repeating  the  .same  irregular  jerking  movements. 
The  gait  is  especially  peculiar,  for  flic  first  few  .steps  perhaps  nearly  normal, 


638  FUNCTIONAL    NEBVOUIS   DISK  ASKS. 

when  siitldenly  it  is  interfered  witii  by  one  leg  being  thrust  violently  forward 
and  the  other  one  jerked  uj)  to  it,  so  that  the  subject  seems  to  go  with  a  quick, 
short  hop,  almost  like  a  dancing  step. 

The  course  of  the  disease  is  exceedingly  slow,  and  in  some  cases  many 
years  are  required  before  the  subject  becomes  unfit  for  physical  labor.  The 
mental  condition  is  usually  but  not  always  abnormal :  excessive  irritability, 
moroseness,  melancholia,  chronic  mania,  and  dementia  have  all  been  noted  in 
cases  which  have  been  reported  as  instances  of  liereditary  chorea.  The  reflexes 
are  often  exaggerated,  but  may  be  sluggish.  The  sensations  are  normal.  In 
some  instances  a  peculiar  muscular  stiifness  has  been  noted. 

Treatment. — So  far  as  is  known  no  treatment  is  of  any  avail  in  this  dis- 
order. 

Tetany. 

Definition. — A  chronic  affection  of  unknown  pathology  characterized  by 
tonic  muscular  spasm  accompanied  by  tingling  and  formication. 

Synonym. — Tetanilla. 

Etiolog-y. — Tetany  is  more  frequent  in  males  than  in  females,  is  almost 
confined  to  childhood  and  young  adults,  is  very  often  associated  with  rachitis, 
and  has  repeatedly  followed  removal  of  the  thyroid.  It  is  said  to  be  directly 
produced  by  excessive  lactation,  by  the  puerperal  state,  by  exposure  to  cold, 
by  prolonged  fatigue,  by  exhaustion  from  diarrhoea  or  other  cause,  by  the  irri- 
tation of  intestinal  worms,  by  exposure,  and  even  by  the  rheumatic  diathesis 
or  the  infectious  fevers.  Further,  it  is  affirmed  that  it  may  result  from  exces- 
sive emotion  and  spread  from  patient  to  patient  as  an  epidemic.  Such  epi- 
demics have,  however,  probably  been  hysterical  in  nature. 

Pathology. — There  is  no  known  lesion  in  tetany. 

Symptomatology. — Tetany  consists  essentially  of  successive  tetanic  con- 
vulsive attacks  separated  by  intervals  of  quiet  and  repose.  The  paroxysms 
may  continue  for  some  minutes  or  for  many  hours,  and  may  cease  gradually 
or  abruptly.  Arthralgic  pains,  formications  or  numbness  in  the  hands,  radi- 
ating pains  in  the  fingers,  temporary  partial  blindness,  headache,  sense  of 
fatigue,  etc.  are  assigned  as  occasional  prodromes.  Usually  the  spasms  are 
most  marked  in  the  upper  extremities,  and  sometimes  are  confined  to  them; 
the  fingers  are  often  drawn  together  so  as  to  form  a  cone.  Rarely  there  is  a 
more  accentuated  flexion  of  the  fingers,  and  still  more  infrequently  the  hand 
and  the  fingers  are  stiffly  extended.  The  feet  may  be  attacked  ;  sometimes 
cramps  of  the  calf  occur  without  distortion,  but  in  other  cases  the  feet  are 
violently  extended,  with  the  toes  pointing  downward ;  more  rarely  the  feet 
are  flexed.  The  thigh  usually  escapes,  but  spasm  of  the  abductors  and  cross- 
ing of  the  feet  have  been  noticed.  Only  in  the  severest  cases  are  the  trunk- 
muscles  affected,  but  opisthotonos  and  menacing  dyspnoea  do  occur.  Even 
more  exceptional  than  these  are  spasmodic  closures  of  the  jaw  and  distortions 
of  the  face.  The  course  of  the  disease  may  be  painless ;  sometimes,  however, 
neuralgic  pains  run  along  the  nerves,  and  usually  cramp-pains  are  present  in 
the  affected    muscle.       Anaesthesia   and  analgesia    are    ordinary   phenomena. 


PARALYSIS  AGITANS.  639 

According  to  Erb,  the  iaradic  excitability  of  all  the  muscles  of  the  body 
is  increased.  The  reflexes  are  said  to  be  usnallv  lessened  in  adults,  but  exair- 
gerated  in  children. 

The  so-called  "  facial  phenomena  "  of  tetany  consists  of  contractions  of  the 
facial  muscles  produced  by  a  rapid  series  of  taps  with  a  percussion  hammer 
upon  the  cheek  just  above  and  parallel  with  the  horizontal  ramus  of  the  lower 
jaw.  Schlessinger  affirms,  however,  that  the  phenomenon  is  not  constant  in 
tetany,  and  is  often  demonstrable  in  persons  not  suifering  from  tetany. 

Prog-nosis. — Tetany  usually  ends  in  recovery,  although  it  frequently  lasts 
for  months  or  even  years,  and  has  a  distinct  tendency  to  relapse. 

Diagnosis. — Trousseau  discovered  that  in  tetany,  during  the  periods  of 
relaxation,  and  in  some  cases  even  as  long  as  three  days  after  the  occurrence 
of  a  convulsion,  an  attack  can  be  brought  on  by  pressing  upon  the  principal 
nerve-trunk  or  artery.  By  this  symptom,  by  the  complete  relaxation  between 
the  attacks,  and  by  the  partial  character  of  the  convulsion  tetany  is  distin- 
guished from  tetanus. 

Treatment. — The  treatment  of  tetany  should  be  primarily  directed  to  the 
relief  of  the  bodily  condition  underlying  the  disorder.  Chloral,  bromides, 
the  anaesthetics,  will  to  some  extent  control  the  movements.  The  value  of 
arsenic  has  not  been  determined. 

Paralysis  Agitans. 

Definition. — A  disease  of  advancing  life,  characterized  by  tremors  con- 
tinued during  waking  hours,  associated  with  muscular  weakness  and  rigidity. 
Pathology  uncertain. 

Synonyms. — Parkinson's  disease  ;  Shaking  palsy. 

Etiolog-y. — Paralysis  agitans  rarely  occurs  under  forty  years  of  age,  is  most 
frequent  between  fifty  and  sixty,  more  common  in  men  than  in  women,  and  is 
very  rarely  the  result  of  hereditary  influence.  Violent  fright,  prolonged  anx- 
iety, exposure  to  cold,  violent  physical  injury,  especially  when  accompanied 
with  great  emotional  disturbance,  are  occasional  exciting  causes  of  the  disease. 
In  the  majority  of  cases,  however,  the  development  of  the  disease  is  gradual 
and  without  apparent  reason. 

Pathology. — Some  of  the  most  noted  neurologists  have  failed  to  detect  any 
anatomical  change  in  any  portion  of  the  nerve-centres  in  persons  who  have  long 
suffered  from  paralysis  agitans.  Under  these  circumstances  speculation  has 
been  rife  as  to  the  nature  of  the  disease,  and  various  theories  have  been  brought 
forward.  None  of  these  theories  seem  to  me  very  plausible,  and  certainly  none 
of  them  are  at  all  established. 

Symptomatology. — Paralysis  agitans  usually  comes  on  insidiously  and 
gradually,  although  in  some  cases  the  symptoms  hav<'  (l(Vflo|M'd  a(  oucc  after 
a  sudden  fright  or  other  emotional  storm.  The  nttciiiion  of  the  patient  is  first 
attra(;ted  by  a  treiinu-  in  tln'  liniid  (.r  foot,  or  even  in  one  finger  or  toe.  This 
tremor  at  first  is  transitory,  ••an  l»c  citntrolled,  at  lc:i<l  tcnipoi-arily,  by  an  cHort 
of  the  will,  and  is  suspended  l)y  voluntary  movcnicnt.     Litllc  Wy  little,  without 


640  FUNCTIONAL   NERVOUS  DISEASES. 

anv  fixed  raethotl  of  progression,  it  involves  more  and  more  of  the  body,  be- 
comes more  and  more  settled,  and  at  last  continues  throughout  all  the  waking 
hours,  during  repose  as  well  as  during  action,  and  cannot  be  controlled  at  all 
bv  the  will.  It  often  passes  up  the  arm  first  invaded,  and  then  descends  to  the 
lower  limb  of  the  same  side,  constituting  the  hemiplegic  form  ;  or  it  may  com- 
mence in  a  leg  and  pass  across  the  body  to  the  opposite  leg,  and  produce  a  para- 
plegic variety.  Finally,  all  portions  of  the  body  are  affected  except  the  head. 
The  face  is  very  rarely  attacked  by  the  tremors,  although  in  the  later  stages  it 
puts  on  a  peculiar  fixed,  immovable,  usually  melancholic  expression.  Accord- 
ing to  Charcot,  the  head  is  never  affected,  any  apparent  trembling  of  it  being 
due  to  the  transmission  of  motion  from  the  trunk.  This  absolute  assertion  is, 
however,  not  correct,  as  I  have  seen  typical  cases  of  paralysis  agitans  in  which 
the  muscles  of  the  neck  and  the  head  were  in  constant  tremor;  and  WestphaP 
is  said  to  have  reported  similar  cases.  Loss  of  power  in  the  lips  seems  to  be 
not  infrequent  in  the  advanced  stages,  so  that  there  is  a  tendency  to  dribbling 
of  the  saliva, — a  tendency  which  is  also  in  part  due  to  the  peculiar  prone  posi- 
tion of  the  head.  The  speech  becomes  a  little  slow  and  labored,  but  is  not  pro- 
foundly affected  :  neither  eating  nor  swallowing  is  interfered  with. 

The  tremors  themselves  are  short,  very  rapid,  and  in  some  cases  distinctly 
rhythmical,  especially  in  the  fingers,  where  they  may  assume  somewhat  the 
appearance  of  voluntary  actions,  as  though  the  patient  were  rolling  something 
between  the  digits.  I  have  noticed  in  some  cases  a  distinct  tendency  of  the 
tremors  to  alter  their  rapidity  in  accordance  with  any  rhythmical  sound,  so  that 
their  rapidity  could  be  regulated,  without  the  patient's  being  conscious  of  it, 
by  altering  the  rate  of  vibration  in  the  interrupter  of  a  faradic  battery.  A 
peculiar  rigidity  of  the  muscles  is  characteristic  of  the  advanced  stages.  There 
are  no  violent  contractures,  but  a  characteristic  fixation  of  the  part.  To  this 
statue-like  rigidity  is,  at  least  in  some  measure,  due  the  position  of  the  patient. 
In  standing  the  trunk  is  inclined  forward,  with  the  face  looking  obliquely 
downward ;  the  forearms  usually  flexed  somewhat  upon  the  arms ;  the  hands  a 
little  bent  upon  the  forearms,  and  the  fingers  partially  closed,  so  that  the  hands- 
assume  a  position  similar  to  that  in  which  the  pen  is  held  ;  hence  the  term  of 
"■  writing  hand  "  as  given  by  Charcot.  The  same  tendency  to  flexion  of  the 
legs  exists,  so  that  in  standing  the  knees  are  bent.  Occasionally,  peculiar  dis- 
tortions of  the  hands  or  other  portions  of  the  body  may  be  met  with.  On 
attempting  to  restore  the  normal  position  of  the  parts  the  muscles  usually  offer 
but  little  resistance  until  the  restoration  is  nearly  perfected. 

The  power  of  making  momentary  muscular  efforts  diminishes  very  slowly 
in  paralysis  agitans,  but  even  early  in  the  disease  fatigue  follows  moderate  exer- 
tion, so  that  there  is  soon  a  great  loss  of  endurance.  In  not  rare  cases  there  is 
a  marked  tendency  io  festination  in  the  walk — i.  e.  to  a  progressive  increase  in 
the  raj^idity  of  the  gait.  The  man  seems  to  be  in  continual  danger  of  falling 
forward  when  attempting  to  walk,  so  that  the  leg  has  to  be  thrust  forward  more 
and  more  quickly  in  order  to  prevent  toppling  over,  and  the  walk  becomes 

^  Charie  Ann.,  1878,  p.  405. 


PARALYSIS  AGITANS.  641 

more  and  more  rapid,  and  in  a  little  while  breaks  into  a  rnn,  which  grows 
faster  and  faster  nntil  the  patient  either  falls  or  arrests  his  course  by  seizing 
hold  of  some  stationary  object.  The  peculiar  position  of  the  body  would  api)ear 
to  be  the  cause  of  the  accelerated  gait,  the  head  being  thrown  so  far  forward  as 
to  bring  the  centre  of  gravity  beyond  the  line  of  the  feet.  That  the  festination 
depends  upon  something  more  than  this  is,  however,  shown  by  the  fact  that 
there  are  cases  in  which  the  tendency  is  to  run  backward  instead  of  forward. 
Moreover,  a  very  markedly  bent  position  is  not  incompatii)le  with  a  normal 
gait. 

Sensation  is  not  })rofoundly  affected,  and  in  some  cases  there  is  very  little 
suffering.  Usually,  however,  especially  as  the  disease  advances,  there  is  a  j)er- 
pctual  sense  of  fatigue  in  the  affected  muscles  which  may  amount  to  a  severe 
aching.  Very  frequently  the  patient  complains  of  an  habitual  feeling  of  exces- 
sive heat,  which  may  also  be  manifested  by  a  continual  sweating.  This  sen- 
.sation  of  heat  does  not  depend  upon  any  elevation  of  the  central  bodily  tem- 
perature, which  is  of  normal  intensity.  The  studies  of  Grasset  and  Apollinario, 
however,  indicate  that  there  is  an  elevation  of  the  temperature  of  the  external 
surface  of  the  body.  These  observers  found  that,  whilst  the  tem})erature  of  the 
surface  of  the  forearm  in  the  normal  individual  was  33.6°  C,  in  a  case  of 
paralysis  agitans  placed  under  similar  conditions  of  clothing  and  exposure  the 
temperature  was  36.8°  C. 

The  urine  has  been  chemically  analyzed  by  Regnard,^  who  found  the  urea 
normal,  the  sulphates  less  than  normal.  According  to  Clieron,^  there  is  a 
constant  increase  in  the  quantity  of  the  phosphates,  which  is  characteristic  and 
may  even  precede  the  development  of  the  tremors.  This  important  observa- 
tion needs  confirmation. 

The  course  of  paralysis  agitans  requires  many  years  for  its  full  develop- 
ment, but  if  the  patient  does  not  die  of  an  intercurrent  disorder  he  passes  into 
a  condition  of  hypochondriasis,  great  depression  of  spirits,  loss  of  intellectual 
power,  general  failure  of  nutrition,  marked  emaciation,  loss  of  digestive  power, 
and  general  marasmus,  and  at  last  dies  of  exhaustion,  the  end  often  being 
liastened  by  bedsores  or  other  local  ailments. 

Diag-nosis. — The  diagnosis  of  a  fully-formed  case  of  typical  paralysis  agi- 
tans is  so  easy  as  to  need  no  discussion.  In  rare  cases  it  is  said  that  the  loss 
of  power,  the  rigidity  and  fixedness  of  the  limbs,  and  the  peculiar  gait  develop 
without  the  tremoi-s.  Under  these  circumstances  the  diagnosis  must  be 
reserved  until  the  sym])toms  become  pronounced.  In  certain  cases  and  stages 
of  the  disorder  senile  tremors  may  be  simulated.  In  the  senile  tremor,  how- 
ever, the  head  is  especially  affected,  and  there  are  usiuilly  tremblings  of  the 
tongue  and  lower  jaw.     In  rare  cases  it  is  necessary  to  reserve  the  diagnosis. 

Prognosis. — The  j)rognosis  of  jKiralysis  agitans  is  absolutely  unfavorable, 
the  disease  always  marching  slowly  but  steadily  onward. 

Treatment. — The  treatment  of  paralysis  agitans  is  jialliative.     It  consi.«ts 

chiefly  of  meeting  the  symptoms  as  they  arise,  and  of  enforcing  a  quiet,  reg- 

»  Protjrh  med.,  1877.  '  f '>'<';  1^77,  No.  48. 

Vol.  I.— 41 


642 


FUNCTIONAL    NERVOUS  DISEASES. 


ular  lite,  with  absolute  avoidance  of  physical  or  mental  labor.  Various 
nerve-sedatives,  especially  morphine,  conium,  hyoscyaraine,  and  Indian  hemp, 
are  accredited  by  authorities  with  the  power  of  temporarily  quieting  the 
tremors.  It  is  evident,  however,  that  the  habitual  use  of  such  remedies  must 
in  all  probability  lead  to  the  narcotic  habit.  Arsenic  has  been  recommended, 
but  is  of  very  doubtful  utility.  Electricity  has  been  much  employed,  but  does 
not  seem  to  have  real  value.  In  the  advanced  stages,  when  there  is  much 
sutfering,  the  hot  bath  is  sometimes  of  service,  and  not  rarely  it  becomes  neces- 
sary to  use  narcotics  at  night  to  bring  sleep  and  a  measure  of  relief  from  pain. 
I  have  seen  a  nightly  dose  of  hydrobromate  of  hyoscine  keep  a  patient  com- 
fortable for  several  years  after  the  failure  of  more  frequently  used  analgesics. 

Remote  Effects  of  Traumatism. 

Blows  upon  the  body  or  upon  the  head,  as  well  as  violent  shaking  or  other 
concussion  upon  the  body  without  actual  violence,  may  produce,  first,  local  in- 
jury and  inflammation  at  the  seat  of  the  violence;  second,  traumatic  hysteria; 
third,  the  condition  for  which  I  prefer  the  name  of  "traumatic  neurasthenia." 

In  most  cases  local  inflammation  and  traumatic  neurasthenia  coexist  with  a 
certain  amount  of  hysterical  disorder.  Before  taking  up  traumatic  neuras- 
thenia it  seems  necessary  to  discuss  briefly  the  local  effects  of  traumatism. 

The  paralysis  sometimes  seen  in  a  muscle  which  has  been  violently  struck, 
though  not  lacerated,  is  probably  due  to  a  suspension  of  the  functions  of  the 
nerve-endings.  The  condition  is  rare  except  in  the  deltoid  muscle,  whose 
position  renders  it  exceedingly  liable  to  be  severely  bruised  in  falls.  If  at 
first  local  inflammation  be  set  up,  local  antiphlogistic  treatment  may  be 
required,  and  if  later  the  nerve-trunks  be  found  tender,  blisters  may  be 
applied.  If  there  be  any  hardening  in  the  immediate  neighborhood  of  a 
nerve,  the  latter  should  be  dissected  out  and  thoroughly  freed  from  any  cica- 
tricial or  otherwise  altered  tissue. 

The  hypodermic  injection  of  strychnine,  massage,  and  the  electrical  cur- 
rents are  to  be  employed  for  the  restoration  of  power.  One  object  of  the 
massage  is  to  thoroughly  free  the  muscles  and  muscular  fibre-bundles  from 
binding  exudations.  The  current  to  be  used  is  that  which  produces  the  great- 
est muscular  contraction  with  the  least  pain  to  the  patient. 

When  the  blow  has  been  upon  the  back,  the  result  is  often  the  condition  to 
which  I  have  given  the  name  of  "traumatic  back."  The  symptoms  are — 
tenderness  more  marked  upon  deep  firm  pressure  than  upon  slight  pressure, 
also  iii)()n  jarring;  restriction ' of  movement  by  pain  and  by  spasm  of  the 
erector-spinse  muscles.  Reflex  spasms  are  also  usually  producible  in  the  back 
muscles  l)y  jarring,  pressing  upon  the  head,  or  even  upon  the  vertebral  column. 

The  symptoms  of  "  traumatic  back "  are  probably  due  to  deep-seated 
inflammation  primarily  situated  in  the  fibrous  structure  of  the  vertebral 
column,  and  in  bad  cases  invatling  neighboring  tissues  and  even  involving 
nerve-routs. 

The  treatment  consists  in  the  use  of  local  rest  and  continued  counter-irri- 


SPINAL   NEURASTHENIA.  643 

tation,  the  general  health  being,  of  course,  steadily  maintained.  In  bad  cases 
the  plaster  jacket  or  some  of  its  substitutes  may  be  essential.  I  have  seen 
suspension  very  useful.  The  human  trunk  is  composed  of  two  cones,  of  which 
the  shoulders  and  hips  are  the  respective  bases.  In  the  Sayre  jacket  the  upper 
of  these  cones  is  supported  upon  the  latter  after  the  two  cones  have  been 
dragged  well  apart  by  hanging  the  man  from  his  arm-pits.  Some  years  ago 
it  occurred  to  me  that  the  upper  cone  of  the  body  might  be  used  instead  of 
the  arm-pits  for  the  purpose  of  suspending  the  patient  and  stretching  the  back. 
In  accordance  with  this  thought  I  found  that  suspension  from  the  upper  cone 
can  be  sustained  without  suffering  for  many  hours,  and  that  in  diseases  of  the 
vertebral  column  situated  low  down  it  is  very  advantageous.  When  the  trau- 
matism has  affected  the  lumbar  region  of  the  back  this  treatment  avails  much. 
In  carrying  it  out  the  patient  should  be  suspended  in  the  ordinary  way  for 
putting  on  the  plaster  jacket,  and  when  the  first  layer  of  the  plaster  jacket 
has  been  put  in  place,  two  broad  strong  linen  bandages,  well  wetted,  are  to  be 
so  placed,  one  over  each  shoulder,  that  they  shall  form  above  a  loop,  whilst  the 
ends  hang  down  front  and  back  eight  inches  below  the  plaster  bandage.  With 
new  turns  of  the  plaster  bandage  the  linen  bandage  must  now  be  fastened  intt> 
its  place.  After  this  the  loose  ends  of  the  linen  bandage  hanging  below  the 
plaster  jacket  are  to  be  taken  up  and  incorporated  into  the  turns  of  the  plas- 
ter bandage  necessary  to  complete  the  jacket. 

Spinal  Neurasthenia. 

Definition. — A  condition  of  neurasthenia,  usually  with  hysterical  symp- 
toms, produced  by  severe  injuries. 

Synonyms. — Spinal  concussion  ;  Railway  spine. 

Etiology. — Railroad  injuries,  falls  from  hatchways,  press  of  steam  from 
exploding  boilers,  any  violence  acting  upon  the  trunk  through  crushing  local 
force  so  as  to  greatly  shake  and  shock  the  whole  system,  may  produce  spinal 
neurasthenia. 

Symptomatology. — The  symptoms  of  traumatic  spinal  neurasthenia  may 
appear  at  once  after  the  injury  or  they  may  come  on  insidiously  in  the  person, 
who  has  at  first  believed  himself  uninjured.  The  symptoms  are  subjective  and 
objective.  The  most  important  of  the  subjective  symptoms  are  malaise,  loss 
of  ambition,  marked  increase  of  nervous  irritability,  failure  of  the  power 
of  mental  and  physical  labor,  depression  of  spirits,  occasional  headache,  pro- 
nounced tinnitus  aurinm,  broken  slee)),  loss  of  sexual  power,  and  general 
failure  of  health.  Almost  invariably  to  these  symptoms  are  added  various 
hysterical  manifestations.  Probably  among  these  must  l)e  classed  the  extra- 
ordinarv  cerebral  attacks  which  come  and  go  often  without  obvious  cause  or 
explanation.  Sometimes  these  attacks  reseml>le  petit  mal,  in  tiiat  they  con- 
sist of  short  moments  of  unconsciousness;  sometimes  th(>  paroxysm  is  pni- 
longed  and  consists  of  an  active  delirium,' which  may  amount  to  a  fin*ious 
and  aggressive  mania.  Often  the  patient  has  no  remembrance  of  any  of  these 
attacks.      Distinctly  hysterical   j)aroxysms  are  not    ran-.      Neurasthenic  vaso- 


644  FUNCTIONAL    NERVOUS   DISEASES. 

motor  weakness  is  common,  so  that  sudden  flushings  of  the  face  and  abrupt 
outbreaks  of  sweating  are  frequent.  The  muscular  irritability  is  often  greatly 
augmented,  and  the  knee-jerks  are  exaggerated.  Paradoxical  contractions 
may  often  be  produced  in  the  anterior  muscles  by  flexure  of  the  foot ;  and, 
as  I  have  seen  in  some  cases,  the  slightest  irritation  may  cause  a  general 
reflex  contraction  of  the  erector  pilse  muscle,  with  a  consequent  "  goose-flesh." 
The  activity  of  the  knee-jerk  is  apt  to  vary  from  day  to  day,  and  often,  when 
exao-o-erated  soon  becomes  exhausted  bv  excitation,  so  that  the  muscles  by  and 
bv  fail  to  respond  well  when  the  patellar  tendon  is  repeatedly  and  rapidly 
struck.  General  fatigue  will  often  register  itself  in  the  knee-jerk.  Ankle- 
clonus  is  rare.  The  sexual  power  is  commonly  not  altogether  lost,  but  sexual 
irritability  and  weakness  are  usually  shown  in  men  by  premature  emissions. 
True  diabetes  may  be  present  and  produce  its  ordinary  results.  With  these 
various  symptoms  there  are  usually  pronounced  local  evidences  of  the  sore  back. 

The  course  of  this  disorder  is  excessively  slow.  It  has  very  little  influ- 
ence upon  life,  but  it  produces  a  disablement  and  much  suffering  that  usually 
last  many  years,  and  which  in  bad  cases  may  never  be  recovered  from. 

Diagnosis — The  diagnosis  of  this  disorder  would  be  very  easy  were  it  not 
for  the  medico-legal  complications  which  surround  most  cases.  The  chief  ques- 
tion always  is  whether  the  symptoms  are  real  or  feigned.  Exaggeration  of 
symptoms  in  many  cases  is  almost  a  necessity  of  the  situation.  The  ques- 
tions to  be  determined  by  the  physicians  are — first,  how  much  exaggeration  or 
feigning  exists ;  second,  how  much  the  symptoms  are  those  of  hysteria  and 
how  much  those  of  neurasthenia  ;  third,  how  much  of  local  disease  there  is. 
The  importance  of  these  questions  rests  upon  the  fact  that  traumatic  hysteria 
yields  much  more  readily  to  treatment  than  traumatic  neurasthenia,  and  that 
local  symptoms  which  have  already  lasted  for  some  time  are  only  to  be  over- 
come by  very  long-continued  careful  treatment,  and  are  indeed  prone  to 
increase  rather  than  decrease. 

Treatment. — The  foundation  of  the  treatment  in  these  cases  consists  in 
absolute  rest,  mental  and  bodily.  Long-continued  rest  in  bed,  with  massage 
and  careful  use  of  electricity,  is  often  of  the  greatest  service.  This  rest  must 
continue  for  a  great  length  of  time,  as  a  little  over-exertion  will  overthrow  any 
good  results  already  obtained.  Tonics  are  of  very  little  service.  Narcotics 
for  the  relief  of  pain  and  malaise  often  seem  called  for,  but  their  use  is  always 
attended  with  more  or  less  danger  of  the  narcotic  habit.  In  one  of  the  most 
successful  cases  I  have  ever  seen,  the  patient,  a  medical  man,  treated  himself, 
chiefly  by  drinking  three  or  four  pints  of  strong  ale  a  day.  In  a  person  of 
less  resolution  this  would  have  resulted  in  the  development  of  the  alcoholic 
hal)it.  The  narcotism  of  the  alcohol  and  the  hops  in  this  case  made  life 
endurable,  whilst  the  stimulating  effects  of  the  beverage  were  very  useful  in 
maintaining  the  vital  functions. 

Results  of  Excessive  Exposure  to  Heat. 
Two  distinct  bodily  conditions,  accompanied  with  disorder  of  conscious- 


HEAT  EXHAUSTION.— THERMIC  FEVER.  645 

ness,  arise  during  exposure  to  heat :  they  may  be  respectively  known  as  heat 
exhaustion  and  thermic  fever. 

Heat  Exhaustion. 

Definition. — A  condition  of  profound  general  exhaustion,  with  paralysis 
of  the  vaso-motor  system  and  failure  of  the  general  bodily  temperature,  due 
to  the  combined  action  of  heat  and  exertion. 

The  sense  of  weakness  which  often  accompanies  exertion  in  feeble  persons 
during  the  hot  weather  represents  in  the  mildest  possible  form  the  condition 
under  consideration.  In  more  severe  cases  there  is  distinct  pallor  of  the  coun- 
tenance, with  failure  of  the  muscular  force  and  of  the  circulation,  accompanied 
by  an  overpowering  feeling  of  exhaustion.  In  the  worst  cases  of  heat  exhaustion 
the  svmptoms  develop  ra]>idly,  and  sometimes  with  such  absolute  abruptness 
that  the  patient  falls  in  a  syncopal  condition.  Under  these  circumstances  uncon- 
sciousness or  semi-consciousness  may  exist,  and  be  accompanied  by  muttering 
delirium,  great  restlessness,  facial  expression  of  collapse,  rapid,  feeble,  scarcely 
perceptible  pulse,  and  a  lowered  bodily  temperature.  I  have  myself  known  a 
mouth  temperature  of  95°  F.,  with  complete  collapse. 

It  is  essential  for  the  purposes  of  treatment  that  heat  exhaustion  be  not  con- 
founded with  thermic  fever,  from  which  it  is  at  once  diagnostically  separated 
bv  the  temperature  being  markedly  below  instead  of  above  the  norm.  The 
only  condition  readily  confounded  with  heat  exhaustion  is  collapse  from  cardiac 
disease,  internal  haemorrhage,  malarial  fever,  or  other  affections  occurring  in 
persons  picked  up  in  the  street  and  brought  to  the  physician  without  history. 
In  such  cases,  however,  it  is  very  rare  for  the  temperature  to  fall  as  decidedly 
as  in  severe  heat  exhaustion,  and  peculiar  and  characteristic  symptoms  are 
usually  present. 

The  treatment  of  heat  exhaustion  consists  in  the  free  use  of  external  heat 
(when  it  is  possible,  by  means  of  hot-water  baths),  the  hypodermic  injection  of 
atropine,  strychnine,  and  digitalis  in  order  to  stimulate  the  heart  and  vaso- 
motor system,  with  the  very  moderate  internal  use  of  hot  alcoholic  drinks  and 
ammonia. 

Thermic  Fever. 

Definition. — Fever  produced  by  exposure  to  heat. 

Synonyms. — Heat  fever  ;  Sunstroke  ;  Coup  de  .soleil. 

Etiology. — The  immediate  cause  of  thermic  fever  is  always  exposure  to 
heat,  natural  or  artificial.  Owing  to  the  interference  with  evaporation,  and 
the  consequent  cooling  of  the  body,  heat  in  a  moist  atmosphere  is  much  more 
efficient  than  is  dry  heat ;  hence  sunstroke  is  very  rare  in  dry  hot  climates  and 
frequent  in  tropical  lowlands,  as  well  as  in  sngar-refiueries,  laundries,  and 
other  places  where  men  work  in  damp  hot  air.  Exposure  to  tli(>  direct  rays 
of  the  sun  is  not  necessary,  and  many  of  the  worst  epidemics  have  occurral 
during  tropical  nights. 

Whatever  lessens  the  power  of  the  human  system  to  resist  external  influ- 


646  FUNCTIONAL    NERVOUS   DISEASES. 

ences  may  be  a  predisposing  cause  to  sunstroke.  Chief  among  these  predis- 
posing causes  are  race,  excessive  bodily  fatigue,  and  intemperance.  The  fact 
that  males  are  much  more  frequently  affected  than  females  depends  simply 
upon  the  habitually  greater  exposure  of  men  to  heat.  Races  which  by  long 
living  in  tropical  countries  have  become  accustomed  to  heat  rarely  suffer  from 
sunstroke. 

Symptomatolog-y. — In  its  severest  forms  sunstroke  is  very  apt  to  come 
on  suddenly  and  witiiout  distinct  prodromes,  although  there  may  be  a  sense 
of  great  distress  or  of  a  general  burning  heat  before  the  loss  of  consciousness, 
which  may  also  bo  immediately  ushered  in  by  chroraatopsia,  or  colored  vision, 
the  whole  landscape  being  deluged  in  a  blue,  yellow,  or  red  light.  The  uncon- 
sciousness ordinarily  develops  abruptly,  and  is  complete,  although  very  fre- 
quently it  is  associated  with  muttering  delirium.  There  is  usually  great  mus- 
cular restlessness,  which  in  some  cases  becomes  convulsive  or  is  replaced  by 
violent  epileptiform  convulsions.  Sometimes  the  patient  is  profoundly  relaxed 
and  quiet.  The  surface  of  the  body,  at  first  dry,  often  later  in  the  attack 
gathers  upon  itself  an  excessive  perspiration,  which  does  not,  however,  reduce 
its  burning  heat.  The  face  is  flushed  and  the  eyes  are  suffused.  The  rapid 
pulse  is  sometimes  bounding  and  apparently  strong,  although  almost  invari- 
ably compressible ;  frequently  it  is  feeble  and  even  thready,  especially  if  the 
symptoms  have  lasted  for  some  hours.  Vomiting  is  very  common ;  purging 
is  in  bad  cases  almost  always  present.  The  whole  body  is  apt  to  exude  a  pecu- 
liar odor,  which  is  especially  strong  in  the  faecal  discharges.  The  characteristic 
symptom  is  the  high  temperature,  which,  as  measured  in  the  mouth  or  rectum, 
may  reach  112°  or  113°,  and  is  rarely  below  108°  in  cases  severe  enough  for 
unconsciousness  to  be  present.  The  urine  is  scanty,  sometimes  albuminous, 
not  rarely  finally  suppressed.  The  breathing  is  more  or  less  labored,  and 
often  irregular,  and  toward  the  last  generally  becomes  more  and  more  shallow. 
Although  at  times  the  patient  suffering  from  thermic  fever  may  be  partially 
aroused  by  shouting,  shaking,  etc.,  the  unconsciousness  is  often  absolute.  The 
pupils  are  variable,  sometimes  contracted,  sometimes  dilated. 

Even  in  the  most  severe  forms  of  thermic  fever,  as  seen  in  this  country, 
death  rarely  occurs  under  half  an  hour,  and  usually  is  postponed  for  a  much 
longer  period.  Sometimes  it  is  caused  by  asphyxia,  more  frequently  by  a  slow, 
consentaneous  failure  of  respiration  and  cardiac  action.  There  is,  however,  a 
form  of  sunstroke  rarely  seen  except  in  soldiers  during  battle,  in  which  the 
death  is  due  to  arrest  of  the  heart's  action,  and  is  almost  instantaneous. 

Many  years  ago,  under  the  name  of  ardent  continued  fever,  the  physicians 
of  India  recognized  a  mild  form  of  heat  fever,  and  in  1885,  Dr.  John  Gui- 
teras  showed  that  the  typhoid  fever  of  Key  West  is  of  this  nature.  The 
symptoms  are  irregular  continued  fever,  without  apparent  cause  or  local  dis- 
ease, with  a  tendency  to  weakness  and  the  typhoid  state,  and  not  rarely  with 
.severe  but  not  permanent  local,  nervous,  abdominal,  or  other  disturbance. 
Writers  in  India  state  that  in  that  climate  these  cases  are  apt  to  end  in 
sudden  collapse  and  death. 


THERMIC   FEVER.  647 

As  was  first  pointed  out  bv  Dr.  Comegys,  many  of  the  cases  of  so-called 
entero-eolitis  occurring  in  young  children  during  the  hot  months  are  reallv 
forms  of  thermic  fever.  The  symptoms  in  these  cases  are  high  fever,  dry 
tongue  and  mouth,  rapid  pulse  and  respiration,  intense  thirst,  vomiting,  purg- 
ing of  greenish,  watery,  faecal  or  serous  matters  with  undigested  particles  of 
food,  and  more  or  less  pronounced  evidences  of  cerebral  disturbance,  such  as 
insomnia,  headache,  contracted  pupils,  delirium,  and  finally  coma.  In  some 
cases  the  bodily  temperature  rises  before  death  to  a  point  comparable  with  that 
which  it  reaches  in  sunstroke  of  the  adult. 

Pathology. — The  results  found  in  the  body  after  death  from  thermic  fever 
depend  much  upon  the  course  of  the  disease  and  the  time  at  which  the  })ost- 
mortem  is  made.  Owing  to  the  intense  heat  of  the  body,  post-mortem  changes 
begin  in  the  course  of  a  very  few  minutes,  and  some  of  the  lesions  described 
by  early  writers  were  really  due  to  beginning  putrefaction.  When  the  post- 
mortem is  made  immediately,  the  left  heart  is  found  contracted,  the  right  heart 
usually  engorged,  the  blood  semifluid  and  collected  in  the  venous  trunks,  with 
petechial  spots  upon  the  arterial  coats  or  scattered  through  the  system. 

In  an  elaborate  research  made  many  years  ago  I  proved  that  the  cause  of 
the  symptoms  and  of  the  lesions  of  thermic  fever  is  simply  the  excessive  heat. 
There  is  in  the  pons  or  higher  portion  of  the  nervous  system  a  centre  whose 
function  it  is  to  inhibit  the  production  of  animal  heat,  and  in  the  mcdidla  a 
centre  (probably  the  vaso-raotor  centre)  which  regulates  the  dissipation  of  the 
bodily  heat :  fever  is  due  to  disturbance  of  these  centres,  so  that  more  heat  is 
produced  than  normal,  and  proportionately  less  heat  thrown  oif.  Let  it  be  sup- 
posed that  a  man  is  placed  in  such  an  atmosphere  and  that  he  is  unable  to  get 
rid  of  the  heat  which  he  is  forming.  The  temperature  of  his  body  will  slowly 
rise,  and  he  may  suffer  from  a  general  thermic  fever.  If  early  or  late  in  this 
condition  the  inhibitory  heat-centre  becomes  exhausted  by  the  effort  which  it 
has  been  making  to  control  the  formation  of  heat,  or  becomes  paralyzed  by  the 
direct  action  of  the  excessive  temperature  already  reached,  then  suddeidy  all 
tissues  will  begin  to  form  heat  with  the  utmost  rapidity,  the  bodily  tempera- 
ture will  rise  with  a  bound,  and  the  man  drop  over  with  some  one  of  the  forms 
of  coup  de  soleil.  Under  this  view  of  the  case  the  widespread  popular  belief, 
that  protecting  the  back  of  the  head  and  upper  neck  from  the  direct  rays  of 
the  sun  is  useful  against  sunstroke,  gains  in  significance,  because  it  is  ])ossible 
that  local  heating  of  the  parts  spoken  of  may  occur  and  aid  in  the  j)r()(luction 
of  inhibitory  paralysis. 

Respiration  often  ceases  in  thermic  fever  through  the  paralyzing  influence 
of  the  heat  upon  the  respiratory  centres,  though  in  long-continued  cases 
asphyxia  may  be  due  to  changes  in  the  blood  itself  Cardiac  rigidity  usually 
occurs  directly  after  death  by  the  coagidation  of  the  myosin,  the  temperature 
of  the  body  in  sunstroke  reaching  very  nearly  the  |)oint  at  which  normal 
myosin  coagulates.  Excessive  exertion  so  alters  the  nature  of  myosin  in 
muscle  as  to  cause  it  to  coagulate  much  more  readily  than  is  normal.  I)ur- 
iuf  a   battle  the    mvosin  of  tlx'   whole  body  is  afl'ected  by  the  excessive  eflbrt, 


648  FUNCTIONAL    NERVOUS   DISEASES. 

and  frequently  men  are  found  stiffened  in  the  attitude  in  which  they  have 
been  stoi)ped  by  the  bullet,  instantaneous  death  being  followed  by  instanta- 
neous post-mortem  rigidity.  In  simstroke  occurring  in  battle  or  in  times  of 
excessive  exposure  death,  as  has  already  been  stated,  may  be  instantaneous,  the 
man  being  instantly  overwhelmed,  because,  under  the  conjoint  influence  of  vio- 
lent exertion  and  intense  heat,  the  heart-muscle  has  suddenly  set  itself  from 
life  into  the  rigidity  of  death. 

Treatment. — All  persons  who  are  constantly  exposed  to  high  temperature 
should  keep  the  bodily  health  as  perfect  as  possible  by  avoidance  of  alcoholic, 
sexual,  or  other  excesses  and  of  great  bodily  or  mental  fatigue.  The  diet 
should  be  largely  farinaceous,  and  the  emunctories  be  kept  active  by  the 
eating  of  fruit,  the  free  use  of  water,  and  mild  salines  if  necessary.  Large 
draughts  of  intensely  cold  ice-water  may  do  harm  in  heated  persons  by  sud- 
denly chilling  the  stomach,  but  cold  water  taken  in  moderate  quantity,  at  short 
intervals,  by  its  action  in  reducing  the  general  temperature  and  in  aiding  free 
perspiration,  does  good.  The  addition  of  claret  or  some  other  substance  which 
mildly  stimulates  the  gastro-intestinal  tract  and  the  skin  may  be  of  great  ser- 
vice in  special  cases. 

In  mild  cases  of  continued  or  subacute  thermic  fever  the  basis  of  the  treat- 
ment should  be  the  use  of  the  cold  bath.  The  plan  adopted  by  Guiteras  at 
Key  "West  was  to  wrap  the  patient  in  a  dry  sheet,  lift  him  into  a  tub  of  water 
having  the  temperature  between  80°  and  85°,  and  then  rapidly  cool  this  water 
by  means  of  ice.  The  time  of  the  immersion  lasted  from  fifty  to  fifty-five 
minutes,  it  being  regulated  by  the  thermometer  in  the  mouth  of  the  patient. 
The  patient  was  then  lifted  out  upon  a  blanket,  the  skin  partially  dried,  and 
the  body  covered.  Guiteras  found  great  advantage  by  giving  a  moderate  dose 
of  whiskev  and  thirtv  minims  of  the  tincture  of  dio-italis  twentv  minutes  after 
the  bath.  He  states  that  it  is  very  important  to  avoid  currents  of  air  blowing 
upDii  the  patient,  and  to  have  the  bath  given  in  a  small  warm  room.  The 
result  of  the  bath  was  invariably  a  lowering  of  the  temperature,  a  reduction 
of"  the  rate  of  the  pulse  and  respiration,  and  a  refreshing  sleep.  After  the 
second  bath  the  course  of  the  temperature  seemed  permanently  influenced  for 
the  better.  It  was  never  necessary  to  give  more  than  two  baths  in  the  twenty- 
four  hours,  but  in  some  cases  they  had  to  be  used  for  many  days. 

In  acute  thermic  fever  immediate  reduction  of  the  bodily  temperature  is 
urgently  indicated.  Any  prodromes  should  be  the  immediate  signal  for  with- 
drawal from  exposure  to  heat,  and  the  use  of  the  cold  bath  if  the  bodily  tem- 
perature be  above  the  norm.  As  soon  as  a  patient  falls  with  sunstroke  he 
should  be  carried  into  the  shade  with  the  least  possible  delay,  his  clothing 
removed,  and  cold  affusions  over  the  chest  and  body  be  practised.  This  must 
not  be  done  timidly  or  grudgingly,  but  most  freely.  In  many  cases  the  best 
resort  will  be  the  neighboring  pump.  In  the  large  cities  of  the  United  States 
during  the  hot  weather  hospital  ambulances  should  be  furnished  with  a  medical 
attendant  and  with  ice  and  antipyrin,  so  that  when  a  sunstroke  patient  is  reached 
he  may  be  immediately  stripped  underneath  the  cover  of  the  ambulance,  and 


THERMIC   FEVER.  649 

remedial  measures  applied  during:  Ids  ])assage  to  the  hospital.  I  believe  many 
lives  are  sacrificed  hy  the  loss  of"  the  critical  moments  in  the  interval  between 
the  finding  of  the  patient  and  his  reaching  the  hospital  ward.  If  circumstances 
favor,  instead  of  the  cold  affusion  rubbing  with  ice  may  be  practised.  The 
patient  should  be  stripped  and  the  whole  body  freely  rubbed  with  large  masses 
of  ice.  When  practicable,  a  still  better  plan  is  to  place  the  patient  in  the  cold 
bath  (50°  F.).  The  employment  of  enemata  of  ice-water,  as  originally  sug- 
g(>sted  by  Parkes,  may  sometimes  be  opportmie.  In  using  these  various  meas- 
ures it  must  be  borne  in  mind  that  the  indication  is  the  reduction  of  tempera- 
ture ;  if  the  means  employed  do  not  accomplish  this,  they  do  no  good. 

The  thermometer  should  always  be  placed  in  the  rectum  or  the  mouth,  the 
amount  of  cooling  of  the  axillary  surface  not  being  a  correct  guide.  Care  is 
sometimes  required  not  to  overdo  the  use  of  the  cold  bath.  In  the  cases 
which  have  come  under  my  own  observation  after  the  use  of  the  cold  bath  but 
little  treatment  has  been  required.  If,  however,  the  period  of  insensibility  has 
lasted  too  long,  there  may  be  no  return  to  consciousness,  even  though  the  bodily 
temperature  be  reduced  to  the  norm.  Under  such  circumstances  the  case  is 
almost  hopeless,  but  the  symptoms  may  be  met  as  they  arise,  and  a  large  blister 
applied  to  the  whole  shaved  scalp. 

When  relapses  of  fever  occur,  they  should  be  met  by  the  use  of  cold,  but 
such  relapses  can  generally  be  prevented  by  giving  antipyrin  with  small  doses 
of  morphine.  In  thermic  fever  hypodermic  injections  of  morphine  should  be 
given  when  severe  convulsions  occur.  Venesection  may  sometimes  be  advan- 
tageously practised  in  the  onset  of  a  severe  thermic  fever,  especially  when  the 
means  of  applying  external  cold  are  not  immediately  at  hand  ;  but  much  care 
and  judgment  are  required  in  using  the  measure.  When  excessive  headache 
with  strong  pulse  follows  immediately  upon  a  sunstroke,  free  venesection 
may  be  required  to  save  the  brain  or  its  membranes  from  an  acute  inflam- 
mation. 

Sequelae. — The  mildest  sequelae  after  thermic  fever  are  inability  to  bear 
exposure  to  heat  without  cerebral  distress  or  pain,  with  more  or  less  marked 
failure  of  general  vigor,  dyspeptic  symptoms,  and  other  indications  of  disturbed 
innervation.  In  other  cases  the  symptoms  are  more  decided.  Pain  in  tiie 
head  is  usually  prominent:  it  may  be  almost  constant  for  months,  but  is 
always  subject  to  exacerbations.  It  sometimes  seems  to  fill  the  whole  cranium, 
but  not  rarely  is  fixed  to  one  spot,  and  I  have  seen  it  associated  with  pain  in 
tlu!  upper  cervical  spine  and  decided  stiffness  of  the  muscles  of  the  neck. 
With  it  may  be  vertigo,  decided  failure  of  memory  and  of  the  power  of  fixing 
the  attention,  with  excessive  nervous  irritability.  When  the  symptoms  aj^proach 
this  point  in  severity  there  is  usually  marked  lowering  of  the  general  health, 
loss  of  strength,  ])ossibly  some  emaciation,  and  the  j^ecidiar  invalid  look 
produced  by  chronic  disease.  In  rare  cases  ejjileptic  convulsions  and  very 
pronounced  evidences  of  chronic  cerebral  inniimmatiou  are  j)resent.  The 
symptom  which  I  believe  always  to  be  present,  and  to  be  of  diagnostic  import, 
is  the  inability  to  withstand  heat.     This  is  shown  not  oidv  (luring  the  summer 


650  FUNCTIONAL    NERVOUS   DISEASES. 

months,  but  in  most  cases  headache  and  severe  general  distress  are  produced 
by  going  into  hot  rooms  even  in  winter. 

The  lesion  underlying  these  sequelae  of  sunstroke  is  raeningo-cortical  irri- 
tation, with  in  severe  cases  distinct  chronic  meningitis.  The  treatment  is, 
first,  absolute  avoidance  of  any  exposure  to  even  moderate  heat,  combined  with 
intellectual  and  physical  rest ;  second,  the  treatment  of  non-specific  chronic 
meningitis — i.  e.  local  bleedings  and  very  free  counter-irritation,  especially  by 
means  of  the  actual  cautery,  combined  with  the  internal  administration  of  mer- 
curials and  the  iodide  of  potassium  in  small  continuous  doses;  third,  the 
restriction  to  a  farinaceous,  non-irritating  diet,  and  the  careful  attention  to  all 
minor  symptoms  as  they  arise.  The  persistent,  merciless  use  of  the  actual 
cautery  T  have  seen  achieve  extraordinary  results  in  severe  cases. 


Caisson  Disease. 

Definition. — A  peculiar  aifection  produced  by  continued  exposure  to  a 
highly  compressed  atmosphere. 

Synonym. — Diver's  paralysis. 

^tiolog-y. — The  only  known  cause  for  this  affection  is  working  in  caissons 
during  bridge-building  or  other  enterprises  in  which  water  is  kept  out  of  the 
caisson  by  highly  compressed  air.  In  passing  from  these  chambers  the  men 
go  through  an  outer  compartment,  so  arranged  that  the  pressure  can  be  grad- 
ually brought  back  to  the  norm.  A  too  rapid  passing  from  the  innermost 
caisson  to  the  outer  air  is  exceedingly  deleterious,  but  no  precautions  can  pre- 
vent the  disease  from  attacking  a  proportion  of  the  workmen. 

Pathology. — The  pathology  of  caisson  disease  is  j^ractically  unknown. 
The  theory  that  the  symptoms  are  due  to  sudden  evolution  of  compressed  gas 
from  the  blood  into  the  nerve-centres  is  not  proven.  It  may  be  that  the  dif- 
fi(nilty  lies  in  the  coats  of  the  small  blood-vessels.  In  a  few  cases  in  which 
autopsies  have  been  obtained  long  after  the  commencement  of  the  disease  dis- 
seminated focal  myelitis  has  been  found. 

Symptomatolog'y. — The  symptoms  of  caisson  disease  usually  develop  in 
from  half  an  hour  to  two  hours  after  the  return  of  the  subject  to  the  surface 
of  the  earth.  Violent  pains  occur  in  the  limbs  and  in  the  hands,  followed  in 
a  few  minutes  by  progressive  loss  of  motor  and  sensory  power  in  the  legs. 
Notwithstanding  the  ansesthesia  may  become  complete,  the  pains  continue, 
whilst  headache,  dizziness,  double  vision,  incoherence  of  speech,  mental 
aberration,  and  sometimes  unconsciousness,  rapidly  develop.  The  patient 
may  convalesce  in  a  few  days,  or  death  may  take  place  quickly  with  apoplec- 
tic symptoms,  or  may  follow  from  paralytic  bedsores  and  cystitis  after  some 
months.  Usually,  however,  recovery  occurs  after  a  prolonged  period  of  atro- 
cious suffering  and  motor  disablement. 

Treatment. — There  is  no  specific  treatment  of  this  affection  :  all  that  can 
be  done  is  to  meet  the  symptoms  as  they  arise. 


OCCUPATION  NEUROSES.  651 

Occupation  Neuroses. 

Definition. — Localized  motor  affections  produced  by  the  excessive  use  of 
groups  of  muscles  in  professional  or  other  business  pursuits. 

Etiolog-y. — Whenever,  as  in  many  of  the  occupations  by  which  men  earn 
their  livelihood,  there  is  required  an  almost  indefinite  repetition  of  a  more  or 
less  complicated  set  of  movements  on  the  part  of  certain  groups  of  muscles, 
peculiar  local  disturbances  of  muscular  action  are  liable  to  be  developed.  The 
symptoms  are  usually  so  entirely  local  as  naturally  to  lead  to  the  supposition 
that  the  affection  is  purely  a  peripheral  one,  but  a  wider  study  shows  that  the 
disease  must  be  connected  with  a  disordered  condition  of  the  nerve-centres. 
Thus,  if  the  victim  attempt  to  substitute  the  left  hand  for  the  disabled  right 
hand,  the  disorder  usually  soon  appears  in  the  left  hand.  Again,  general 
overwork,  anxiety,  and  depressing  emotion  sometimes  play  a  very  distinct  etio- 
logical role,  and  in  a  number  of  instances  I  have  seen  the  ''writer's  cramp" 
appear  as  the  first  symptom  of  a  general  nervous  breakdown.  Occupation 
neuroses  may  indeed  be  looked  Jipon  as  local  neurasthenia,  having  the  same 
relations  to  general  neurasthenia  that  every  local  neurasthenia  has.  (See 
page  587.) 

Occupation  neuroses  are  more  frequent  in  middle  adult  life  than  in  either 
extreme  of  age,  and  are  much  more  abundant  among  men  than  among  women, 
simply  because  the  active  period  of  male  adult  life  is  that  of  labor. 

The  most  common  of  the  occupation  neuroses  is  the  so-called  ''  writer's 
cramp/'  but  the  variety  of  cases  which  occur  in  real  life  is  almost  indefinite. 
Professional  pianofortists  frequently  suffer  pianoforte-player's  cramp,  which 
for  obvious  reasons  is  more  frequent  among  women  than  among  men.  Vio- 
linists are  liable  to  a  similar  affection  in  either  hand  ;  seamstresses,  tailors, 
sailmakers  sometimes  develop  the  sewer's  cramp.  The  telegraphist's  cramp  is 
esjiecially  frequent  among  those  who  use  the  Morse  machine.  Dancer's  palsy, 
or  cramp  affecting  especially  the  muscles  of  the  calf,  is  very  rare  among  men, 
being  seen  almost  exclusively  in  the  professional  danseuse.  Hammer  palsy 
attacks  chiefly  the  muscles  of  the  right  upper  arm,  and  is  especially  frequent 
among  gold-beaters,  but  is  occasionally  seen  among  smiths ;  the  latter  artisans 
are  also  liable  to  suffer  from  chisel  cram,p,  affecting  the  left  hand,  produced  by 
the  continuous  holding  of  the  chisel  or  similar  instrument.  Money-counters, 
watchmakers,  knitters,  engravers,  indeed  the  whole  list  of  artisans,  are  occa- 
sionally disabled  by  peculiar  occupation  neuroses. 

Pathology. — No  anatomical  changes  are  known  to  exist  in  writer's  cramp 
and  allied  disorders,  and  it  does  not  seem  worth  while  to  discuss  the  various 
theories  in  detail.  The  condition  is  probably  one  of  local  ncMirasthcnia,  with 
irritabilitv  of  tlio  affected  centres. 

Symptomatolog'y. — The  symptoms  ol"  occupation  neuroses  arc  due  to  the 
excessiv(!  repetition  of"  movements  which  require  exceedingly  fine  co-ordination, 
and  differ  essentially  from  the  siriiple  muscular  exhaustion  which  occasionally 
is  produced   by  severe  muscular  efforts.     The  ciiaracteristic  symptom  of  the 


052  FUNCTIONAL    NERVOUS   DISEASES. 

occupation  neuroses  is,  therefore,  that,  although  the  disablement  for  the  habit- 
ual fine  action  may  be  almost  complete,  muscular  power  remains,  at  least  at 
first,  for  coarse  actions.  Thus,  a  man  that  cannot  grasp  the  pen  may  readily 
wield  a  fifty-pound  dumb-bell. 

The  most  marked  symptoms  of  these  neuroses  are  pain  and  spasm.  In  1868, 
Moritz  Benedict  stated  that  there  were  three  forms  of  occupation  neuroses — 
the  paralytic,  the  spasmodic,  and  the  tremulous.  These  varieties  undoubtedly 
exist  in  nature,  although  not  absolutely  separated  from  one  another,  the  dis- 
tinction between  them  being  simply  that  in  some  cases  the  paralytic  symptoms 
are  most  marked,  whilst  in  others  the  spasm  or  the  tremor  is  the  most  pro- 
nounced. According  to  ray  own  observation,  the  paralytic  form  of  the  affec- 
tion is  much  the  most  frequent,  although  some  authorities  assert  that  the 
spasmodic  is  the  ordinary  variety. 

As  it  is  not  possible  in  the  allotted  space  to  describe  in  detail  even  the 
majority  of  the  occupation  neuroses,  I  shall  take  the  most  common  of  them, 
the  writer^s  cramp,  as  a  type  of  the  disorder. 

In  the  paralytic  form  of  writer's  cramp  the  first  symptom  is  usually  a 
painful  feeling  of  fatigue  in  the  arm,  which  is  often  associated  with  formica- 
tion and  numbness,  but  usually  not  with  true  ansesthesia  or  hypereesthesia. 
Only  in  rare  cases  can  tenderness  be  found  over  the  nerve-trunks.  The  pain 
is  always  increased  by  writing,  and  at  last  it  grows  so  intolerable  as  altogether 
to  forbid  the  use  of  the  pen.  With  this  fatigue  and  pain  there  are  usually  a 
sense  of  stiflPness  and  often  a  distinct  muscular  resistance  when  the  eifort  is 
make  to  grasp  the  pen.  At  first  no  pain  is  felt  when  the  arm  is  not  used,  and 
during  use  the  pain  is  confined  to  the  arm  itself;  but  by  and  by,  if  efforts  be 
persisted  in,  the  sense  of  fatigue  becomes  more  or  less  permanent,  and  extends 
upward  from  the  arm,  and  may  often  be  felt  as  a  distinct  pain  between  the 
shoulders.  During  all  this  time  the  power  of  the  muscles  for  coarse  work  is 
in  most  cases  not  sensibly  impaired,  but  the  execution  of  any  form  of  fine 
work  is  usually  interfered  with. 

Even  in  the  paralytic  form  of  writer's  cramp  there  is  a  certain  amount  of 
irregular  spasmodic  contraction  in  the  muscles  during  the  act  of  writing,  as  is 
esj)ecially  shown  by  the  stiffness  and,  occasionally,  by  the  cramp  of  the  fingers 
around  the  pen ;  but  in  the  spasmodic  form  of  the  affection  irregular  muscular 
contractions  are  the  dominant  symptom.  At  first  these  are  only  simple,  slight 
spasmodic  movements  of  the  thumb  and  first  finger,  so  as  to  produce  an  irreg- 
ular stroke  in  the  writing,  but  after  a  time  the  spasms  become  stronger  and 
more  widespread.  By  a  sudden  extension  of  the  finger  the  pen  is  dropped,  or 
by  a  spasmodic  action  of  the  opponens  pollicis,  with  abduction  and  coincident 
flexion  of  the  index  fingers,  the  pen  is  rapidly  moved  from  the  paper,  or  occa- 
sionally a  violent  spasmodic  flexion  of  all  the  concerned  fingers  holds  the  pen 
as  in  a  vice.  In  extreme  cases  all  the  muscles  of  the  forearm  are  involved  ; 
and  it  is  asserted  that  the  muscles  of  the  arm  and  shoulders  may  be  affected, 
although  I  have  never  seen  an    instance  of  this. 

Much  the  rarest  form  of  writer's  cramp  is  that  in  \vhich  tremors  are  the 


OCCUPATIOX  NEUROSES.  653 

most  prorninont  manifestation.  When  any  attempt  to  write  is  made,  trem- 
blings in  the  hand  and  forearm,  and  in  extreme  instances  in  the  arm  itself, 
come  on.  The  pen,  following  the  tremors  rather  than  the  effort  of  the  will, 
soon  makes  nothing  but  irregular  undulating  or  angular  strokes,  in  which  not 
even  the  \'estige  of  a  letter  can  be  made  out.  I  have  never  seen  a  case  in 
which  tremors  existed  as  the  sole  symptom,  but  I  have  seen  them  very  marked 
in  the  spasmodic  form  of  telegrapher's  cramp,  and  have  noted  their  per- 
sistence during  almost  all  forms  of  voluntary  movement,  even  after  the  occu- 
pation had  been  abandoned  for  months. 

Prog-no^is. — The  prognosis  in  writer's  cramp  is  good,  provided  that 
absolute  rest  from  the  original  cause  of  the  disorder  can  be  obtained.  The 
course  of  the  attection  is,  however,  slow,  and  the  disablement  has  a  great 
tendency  to  return,  even  after  apparent  health  has  been  restored,  upon  any 
repetition  of  the  work. 

Treatment — In  the  circumstances  which  surround  most  patients  the  treat- 
ment of  writer's  cramp,  as  in  other  occupation  neuroses,  is  troublesome,  since, 
except  in  the  very  slightest  forms  of  the  affection,  total  abstinence  from  writ- 
ing for  a  protracted  period  is  essential  to  the  cure.  Moreover,  the  symptoms 
have  a  great  tendency  to  recur  upon  recurrence  to  writing.  Much  can  be  done 
to  prevent  the  original  development  of  writer's  (!amp,  and  also  relapses,  by 
writing  with  the  arm  rather  than  the  hand.  Any  person  who  begins  to  feel 
discomfort  during  writing  should  at  once  adopt  the  freer  style,  A  penholder 
of  cork,  half  an  inch  in  diameter,  is  of  great  advantage;  the  quill  pen  is 
said  to  be  superior  to  any  steel  pen,  and  certainly  the  blunt-pointed  steel  pen 
made  in  imitation  of  the  quill  pen  is  much  better  than  the  ordinary  sharp- 
pointed  instrument.  In  free  writing  the  movement  is  chiefly  from  the  shoul- 
der-joint; for  the  development  of  the  method  Gowers  suggests  that  the  learner 
should  draw  a  line  across  a  sheet  of  paper  with  the  arm  moved  as  a  whole  from 
the  shoulder ;  then  that  he  should  make  a  similar  but  wavy  line ;  then  increase 
the  wavy  character  of  the  line  and  then  the  slope  of  the  waves,  so  that  at  last  he 
forms  the  line  like  a  series  of  m's — mmmmm — the  letters  being  joined  together. 
From  these  letters  the  transition  to  other  letters  will  be  easy.  A  person  learn- 
ing this  method  should  learn  to  form  a  whole  line  of  words  without  lifting  the 
hand  from  the  paper,  the  hand  holding  the  large  pen-holder  lightly.  Much 
better  even  than  this  method  of  writing  is  the  use  of  one  of  the  type-writing 
machines.'  When  it  is  necessary  for  the  subject  of  the  disease  to  continue 
the  writing  at  all  hazards,  the  left  hand  may  be  employed.  In  writing  with 
it,  it  will  be  found  easier  to  reverse  the  lines — i.  e.  to  write  with  the  slope  from 

'  Authors  and  other  persons  who  compose  as  they  write  will  find  an  exlraordiiiiiry  savinfc 
of  nerve-force  and  time  by  the  use  of  the  short-hand  amanuensis.  The  hahit  of  dictalion  can 
by  most  persons  be  readily  formed:  it  nnist  be  remembered,  however,  that  the  person  will 
dictate  as  much  in  one  liour  as  lie  will  write  in  three,  so  that  the  dictation  means  more  expen- 
diture of  })rain-force  in  the  same  period  of  time  than  occurs  in  composing  by  writinp.  The 
author  who  dictates  must  work  fewer  hours  a  day,  but  even  then  will  accomplish  more  than  he 
would  with  his  own  pen. 


654  FUNCTIONAL    NERVOU^S   DLSEASIu^. 

left  to  right.     Usually  the  left  hand  soon  develops  cramp,  but  occasionally  it 
remains  free  if  great  care  be  taken  not  to  overwork  it. 

The  direct  treatment  of  the  arm  suffering  from  writer's  cramp  yields  very 
unsatisfactory  results.  No  internal  medication  is  of  any  use,  save  only  as  it 
may  benefit  the  general  health  of  the  patient  and  overcome  the  neurasthenic 
tendency  apt  to  exist  in  these  cases.  Rest,  massage,  and  electricity  are  the 
tiiree  asencies  at  hand.  As  alreadv  stated,  rest  must  be  absolute  and  long 
continued.  Massage  seems  to  be  of  distinct  value.  Electricity  has  been  very 
largely  employed,  and  is  by  some  authorities  strongly  commended,  by  others 
spoken  of  with  despair.  It  seems,  in  fact,  to  do  good  in  some  cases,  but  very 
often  its  influence  is  scarcely  perceptible.  Faradization  may  do  harm,  as  the 
muscles  are  commonly  irritable;  it  rarely,  if  ever,  does  good.  The  best  appli- 
cation is  the  long-continued  use  of  a  mild  current  of  galvanic  electricity  })assed 
down  the  nerve  of  the  affected  member,  of  just  such  strength  as  to  be  distinctly 
but  not  painfully  perceived.  A  small  positive  pole  should  be  placed  over  the 
nerve-trunks  in  the  groove  of  the  inside  upper  arm,  whilst  the  hand  rests  upon 
a  large  well- wetted  sponge  connected  with  the  negative  pole. 

Headache. 
Although   pain   in  the  head  is  a  symptom,  yet  it  so  frequently  constitutes 
the  main  complaint  of  patients  that  it  seems  necessary  to  give  it  here  separate 
consideration.     For  the  purpose  of  brief  discussion  headaches  may  be  arranged 
in  four  classes,  as  follows  •} 

1.  Organic  headaches,  due  to  disease  of  the  brain  or  its  membranes. 

2.  Toxsemic  headaches,  due  to  a  poison  either  produced  within  the  body  or 
received  from  without. 

3.  Sympathetic  headaches,  due  to  some  peripheral  lesion. 

4.  Headaches  which  are  not  included  in  the  other  groups,  and  to  which  the 
name  of  nervous  may  be  given,  with  the  understanding  that  the  title  carries  no 
etiological  significance.  In  this  group  are  placed  many  headaches  of  whose 
ultimate  cause  we  are  ignorant. 

Unfi)rtunately,  it  is  not  possible,  by  any  character  of  the  headache  itself,  to 

'  It  seems  proper  here,  also,  to  give  anew  a  warnin":  against  mistaking  the  pain  of  an  acnt« 
glaucoma  for  a  headache.  The  pain  of  glaucoma,  which  may  develop  abruptly,  often  centres 
in  the  eyeball,  but  may  seem  to  have  its  chief  focus  in  the  supraorbital  notch:  not  rarely  it 
shoots  over  the  foi-fhead  and  into  the  cheek  and  temple,  reaching  even  to  the  occiput,  and  filling 
the  whole  side  of  the  head  with  agony.  If,  as  usunlly  happens,  there  be  fever,  with  severe 
vomiting,  the  patient  may  be  thought  to  be  suffering  from  a  bilious  or  malarial  attack,  and  the 
eye  be  irretrievably  damaged  before  the  true  nature  of  the  paroxysm  is  discerned.  This  can  be 
avoided  by  ])aying  attention  to  the  following  points:  the  eye  shows  evidences  of  inflammation 
in  congestion  and  swelling  of  the  conjunctiva  and  even  of  the  lids;  the  cornea  is  somewhat 
misty,  presenting  the  appearance  sometimes  spoken  of  as  "  steaminess,"  and  its  sensitiveness  to 
the  touch  of  a  canicl's-lKiir  pencil  is  diminished ;  the  ])Ui)il  is  sluggish,  often  somewhat  dilated ; 
on  palpating  the  two  eyeballs  simultaneously  with  the  forefingers  the  aflTected  eye  is  felt  to  be  the 
liarder,  and  the  patient  often  complains  of  a  sense  of  tension  in  the  ball;  vision  is  less  acute  in 
tlie  affected  than  in  the  sound  eye.  In  case  of  doubt  it  is  the  duty  of  the  practitioner  to  call  in 
an  oculist  at  once. 


HEADACHE.  655 

<lccide  to  which  of  these  classes  it  belongs.  It  is  impossible  to  diagnose  the 
nature  of  a  lieadache  by  a  study  of  the  headache  itself.  The  organic  headache 
is  of  course  very  persistent,  but  its  true  nature  is  only  to  be  made  out  by  the 
discovery  of  some  other  symptom  of  organic  brain  disease.  Exclusion  of  other 
possible  causes  may  lead  us  to  suspect  the  origin  of  such  a  lieadache. 

Toxemic  Headache. — Of  the  toxtemic  headaches  the  most  important  are 
the  malarial,  rheumatic,  lithpemic,  alcoholic,  caflf'einic,  gastric,  and  other  head- 
aches due  to  alterations  of  the  blood  produced  by  diseases  of  the  kidneys, 
heart,  and  lungs. 

The  derangement  of  the  health  produced  by  malaria  may  cause,  nervous 
headache,  but  the  specific  malarial  headache  occurs  periodically,  usually  in  the 
form  of  the  so-called  ''  brow  ague,"  in  which  an  intense  pain  rapidly  develops 
at  fixed  hours  in  the  immediate  neighborhood  of  one  supraorbital  foramen. 
This  pain  lasts  from  five  to  ten  hours,  is  often  of  frightful  intensity,  and  may 
or  may  not  be  associated  with  fever  and  sweat  or  other  indications  of  a  malarial 
paroxysm.  The  nature  of  such  a  headache  is  recognized  by  its  periodicity  and 
by  its  yielding  to  very  large  doses  of  quinine. 

The  rheumatic  headache  is  ordinarily  heavy,  aching,  may  take  the  form  of 
the  shooting  pains  of  a  neuritis,  and  may  be  without  any  character  indicating 
its  nature.  Usually  it  is  to  be  recognized  by  the  marked  soreness  of  the  scalp 
which  accompanies  it.  In  doubtful  cases  the  effect  of  the  salicylates  should  be 
tried. 

The  lithsemic  headache  in  its  usual  form  is  dull,  heavy,  and  often  worse  in 
the  morning.  It  is,  sometimes,  however,  atrociously  acute,  paroxysmal,  and 
continuing  with  such  persistency  as  to  suggest  an  organic  cause.  Especially  is 
the  organic  picture  complete  in  those  cases  in  which  the  headache  is  associated 
with  vertigo,  staggering,  or  even  epileptoid  spells.  I  believe  that  usually  in 
these  cases  there  is  cither  a  gouty  deposit  in,  or  a  gouty  inflammation  of,  the 
meninges.  The  diagnosis  of  a  litlixmic  headache  rests  on  the  existence  of 
lithsemia  and  the  exclusion  of  other  forms  of  headache. 

The  abuse  of  coffee  and  tea,  especially  in  overworked  women  of  neurotic 
temperament,  is  a  frequent  cause  of  severe  obstinate  headaches  which  are  not 
reached  by  any  treatment  until  total  abstinence  from  cafiieinic  drinks  has  l)e(>u 
enforced  for  a  month. 

The  dull,  heavy  headache  of  habitual  indigestion,  with  hepatic  torpor  (the 
so-called  "biliousness"),  is  usually  frontal,  may  be  occii)ital,  and  is  often  asso- 
ciated with  defective  vision,  giddiness,  and  great  depression  of  spirits.  Severe 
head-pain  is  sometimes  due  to  gastric  acidity.  This  headache  is  often  ushered 
in  by  sudden  blindness  and  dizziness,  and  usually  yields  at  once  to  the  admin- 
istration of  ammonia  and  bicarbonate  of  sodium. 

Headache  may  be  the  only  complaine<l-of  symptom  of  diabetes,  uricmia, 
and  the  imju-rfect  aeration  of  the  blood  produced  by  cardiac  or  pulmonic  dis- 
ease. The  form  of  these  headaches  varies  indefinitely  :  the  cause  is  only  to  be 
made  out  by  discovering  the  distant  organic  lesion.  It  must  be  remembered 
that  in   advanced  contracted  kidneys  the  urine  may  l)c  |)ersistently  free  from 


656  FUNCTIONAL    NERVOUS   DISEASES. 

albumin,  the  disease  being  revealed  only  by  the  persistent  low  specific  gravity. 
In  obscure  chronic  headaciie  occurring  in  children  the  condition  of  the  heart 
should  especially  be  looked  after. 

Sympathetic  Headache. — Almost  any  peripheral  irritation  may  in  rare 
cases  produce  pain  in  the  head,  but  the  ordinary  sympathetic  headaches  are 
those  due  to  eye-strain  and  disease  of  the  nose,  though  it  is  sometimes  doubtful 
whether  the  nasal  headache  is  not  at  least  in  part  produced  by  imperfect  respi- 
ration. The  headache  of  eye-strain  is  extremely  frequent,  is  often  frontal, 
not  rarely  occipital,  may  seem  to  have  no  connection  with  the  eye,  or  may 
take  on  the  character  of  almost  any  form  of  headache,  even  that  of  typical 
migraine.  It  is  usually  aggravated  by  the  use  of  the  eyes,  is  apt  to  be  severe 
in  the  morning  after  an  evening  spent  in  a  place  of  amusement,  or  may 
coexist  with  head-pain  of  other  character.  The  only  method  of  detecting  its 
nature  is  the  discovery  and  subsequent  correction  of  the  optical  difficulty. 
The  nasal  headache  is  usually  frontal,  may  be  vertical  or  occipital,  and  may 
take  on  the  form  of  a  migraine.  Its  nature  is  often  immediately  to  be  detected 
by  the  tenderness  of  the  inner  wall  of  the  orbit  when  pressed  upon  by  the 
finger,  or  by  the  pain  caused  by  touching  the  middle  turbinate  bone  with  a 
probe.  In  any  case  of  chronic  headache  with  chronic  nasal  disorder  the  latter 
should  be  carefully  ti-eated. 

Under  the  title  of  nervous  headache  may  be  grouped  anaemic  headache, 
congestive  headache,  the  headache  of  brain-exhaustion,  the  hysterical  headache, 
migraine,  and  certain  rare  headaches  whose  nature  is  obscure,  but  which  may 
be  designated  by  the  misnomer  of  idiopathic  headaches. 

The  headaches  of  anaemia  and  of  exhaustion  are  very  similar  in  their 
nature.  Each  of  them  may  be  accompanied  by  flushing  of  the  face,  redden- 
ing of  the  eyes,  or  sense  of  fulness  of  the  head,  which  may  mislead  the  prac- 
titioner into  supposing  that  there  is  true  brain  congestion.  Often  the  headache 
in  these  cases  is  rather  a  sense  of  distress  and  weight  than  a  true  pain. 

The  headache  of  acute  cerebral  hypersemia  is  very  rare  unless  it  arise  from 
an  exposure  to  excessive  heat,  traumatism,  or  an  organic  cerebral  disease.  It  is 
to  be  recognized  by  the  pulsation  of  the  carotid,  the  strong  full  pulse,  and  the 
tendency  to  coma  or  delirious  disturbance. 

Most  hysterical  patients  suffer  from  severe  headaches  of  various  character. 
Almost  characteristic  is  the  so-called  clavus,  a  pain  situated  in  the  middle  of 
the  top  of  the  head  in  a  point  so  small  that  it  can  almost  be  covered  with  the 
point  of  the  finger.  The  hysterical  headache  is  apt  to  be  increased  at  the  men- 
strual period,  and  to  be  suddenly  removed  by  pleasurable  mental  excitement. 
Migraine,  Megrim,  or  " sick  headache"  has  for  its  essential  feature  a  par- 
oxysmal headache,  which  in  the  great  majority  of  cases  appears  first  at  early 
puberty,  and  continues  in  women  up  to  the  menopause  or  in  men  to  advanced 
middle  life.  In  its  details  the  paroxysm  varies  in  different  individuals,  but 
usually  conforms  more  or  less  to  the  following  type :  For  some  hours  before 
the  attack  the  patient  suffers  from  malaise,  often  with  chilliness  and  a  sense 
of  languor,  or  in  rare  cases  experiences  a  condition  of  peculiar  emotional  and 


HEA  DA  CHE.  057 

mental  activity.  The  attack  may  or  may  not  be  nshered  in  by  distinct  pro- 
dromes. The  pain  is  unilateral  in  the  great  majority  of  cases,  and  is  referred 
to  the  frontal  region,  having  the  focus  at  or  about  the  supraorbital  foramen,  or 
more  rarely  in  the  eye  itself.  It  comes  on  gradually,  becoming  more  and  more 
intense  for  hours,  until  finally  it  is  unbearable.  It  is  generally  described  as 
boring  in  character,  often  throbbing,  and  only  in  very  rare  instances  as  shoot- 
ing into  the  jaws  and  the  neck.  Sometimes  the  occipital  region  may  be  the 
seat  of  the  pain.  At  about  the  time  that  the  pain  reaches  its  greatest  intensity 
nausea  followed  by  vomiting  develops.  The  vomiting  is  usually  rejieated,  and 
is  attended  with  great  bodily  depression.  The  matters  ejected  are  the  contents 
of  the  stomach,  followed  by  mucus  and  bile.  Immediate  relief  often  follows 
the  vomiting.  In  some  cases  the  patient  now  falls  asleep,  and  wakes  free  from 
the  headache ;  in  other  cases  the  headache  gradually  subsides.  The  whole 
paroxysm  lasts  from  five  hours  to  two  or  even  three  days.  During  the  height 
of  the  attack  of  migraine  there  is  generally  intolerance  of  light  and  sound ; 
and  yet,  according  to  E.  Souila/  occasionally  there  is  an  intense  craving  i'ov 
light,  and  even  for  noise. 

Although  the  general  features  of  an  attack  of  migraine  usually  conform  to 
the  account  just  given,  there  are  certain  sym])toms  which  are  occasionally  pres- 
ent and  demand  more  detailed  description.  In  some  cases  the  prodromes  are 
very  marked,  and  include  distinct  disturbance  of  a  special  sense.  The  sight  is 
the  most  frequently  affected,  and  next  after  it  the  smell.  It  is  stated  that  in 
very  rare  cases  a  taste  comparable  to  that  produced  by  passing  an  electric  cur- 
rent through  the  mouth  is  prodromic  of  a  paroxysm  of  migraine ;  more  com- 
mon is  a  peculiar  bitter  taste  in  the  mouth,  which  is  generally  referred  by  most 
patients  to  disorder  of  the  stomach.  This  taste  has  seemed  to  me  tQ  be  closely 
connected  with  a  peculiar,  excessively  disagreeable  odor  of  the  breath,  which 
in  turn  appears  to  be  due  to  the  excretion  of  some  sulphuretted  compounds. 
Jewelry  about  the  person  may  be  very  distinctly  tarnished  during  an  attack. 

As  the  affection  has  come  under  my  notice  in  America  vaso-motor  dis- 
turbance is  not  usually  pronounced ;  but  Eulenberg  distinguishes  two  varieties 
of  migraine  which  he  says  are  typical.  In  the  one,  during  the  height  of  the 
j)aroxysm,  upon  the  affe(!ted  side  the  face  is  pale,  the  pupil  dilated,  the  tempo- 
ral artery  hard,  and  the  temperature  of  the  external  auditory  canal  is  reduced 
one  to  two  degrees  Fahr.  Pressure  upon  the  carotid  on  the  side  of  the  ])ain 
now  increases  the  pain,  while  pressure  upon  the  artery  on  the  ojiposite  side  of 
the  neck  tends  to  relieve  it.  Toward  the  end  of  the  paroxysm  the  face  and  ear 
become  red,  with  a  sensation  of  heat  and  an  absolute  rise  of  the  temperature; 
at  the  same  time  there  is  in  some  cases  a  contraction  of  the  i)ui)il.  In  the 
second  variety  of  migraine  described  by  Eulenberg  there  are  throughout  the 
|)aroxysm  evidences  of  vaso-motor  depression.  Always  at  the  liciglit  of  the 
attack  the  face  is  red  and  hot,  the  conjunctiva  injected,  innl  the  lachrymal  secre- 
tion increased.  The  ear  of  the  affected  side  is  distinctly  hotter  lli.iii  its  i'ellow, 
and  the  sweat  is  very  abundant  at  the  immediate  site  of  the  pain,  or  sometimes 

>  TluHi;  Paris,  1H84,  No.  .lO. 
Vol..  I.  -42 


658  FUNCTIONAL    NERVOUS   DISEASES. 

the  sweating  is  unilateral.  By  compression  of  the  carotid  upon  the  affected 
side  the  pain  is  lessened,  but  it  is  increased  by  pressure  upon  the  artery  of  the 
opposite  side.  It  is  affirmed  that  in  some  cases  the  dilatation  of  the  arteries 
and  veins  can  be  detected  in  the  fundus  of  the  eye.  Toward  the  close  of  the 
attack  the  face  becomes  pale. 

Dr.  Anstie  of  London  states  that  the  pain-storm  or  migraine  may  be  accom- 
panied by  a  temporary  whitening  of  the  hair  at  the  seat  of  the  pain,  and  that 
this  paroxysmal  bleaching,  so  to  speak,  finally  leads  to  a  change  of  color. 

I  have  never  been  able  to  confirm  the  existence  of  the  described  varieties 
of  migraine  or  of  the  trophic  changes  just  spoken  of,  nor  yet  have  I  ever  seen 
a  case  in  which  migraine  has  produced,  by  continually  recurring  paroxysms,  a 
condition  parallel  to  the  status  epilepticus,  such  as  has  been  described  by  Dr. 
F^re  of  the  Bicetre. 

Visual  prodromes  are  pronounced  in  migraine  ophthalmica  (hefniopia  peri- 
odica). The  most  frequent  form  of  visual  disturbance  is  an  amblyopia,  accom- 
panied by  vivid  scintillations  passing  zigzag,  like  the  lines  of  a  fortification, 
over  the  field  of  vision.  When  heraiopia  occurs  it  may  be  either  monocular 
or  binocular ;  sometimes  it  is  lateral ;  in  other  eases  it  occupies  the  superior 
half  of  the  visual  field.  In  the  binocular  form  a  lateral  half  of  the  field  is 
attacked.  The  vision  is  completely  abolished  in  the  affected  portion  of  the 
field,  although  the  total  acuity  of  vision  may  remain  normal.  This  sensory 
<listiirbance  very  rarely  occurs  except  in  persons  who  have  long  suffered  from 
the  migraine.  In  some  cases  it  is  preceded  by  headache,  but  usually  it  devel- 
ops suddenly  as  the  beginning  of  the  paroxysm ;  occasionally  instead  of  hemi- 
opia  a  central  scotoma  is  the  dominant  symptom.  Rarely  this  scotoma  merges 
itself  finally  in  a  hemiopia.  In  rare  cases  these  disturbances  of  sight  are 
replaced  by  distinct  visions  or  hallucinations.  The  olfactory  disturbance  which 
sometimes  ushers  in  a  migraine  is  generally  the  sense  of  a  peculiar  odor,  like 
that  of  osmic  acid,  etc.  The  auditory  prodrome  has  been  variously  described 
as  like  the  sound  which  is  produced  when  a  marine  shell  is  applied  to  the  ear, 
or  as  a  gurgling  similar  to  that  which  is  heard  when  water  enters  the  ear 
durino;  bathino;. 

The  psychical  symptoms  which  accompany  a  migraine  are  usually  not  severe, 
but  in  rare  cases  they  are  very  marked,  affecting  especially  the  emotional  nature, 
causing  in  one  instance  profound  melancholy  and  depression,  in  another  viva- 
city ;  in  either  case  there  is  commonly  an  excessive  irritability.  During  the 
attack,  according  to  the  measurements  of  O.  Berger,  there  is  a  condition  of 
hyportesthesia  of  the  skin  of  the  face,  at  least  so  far  as  the  sense  of  locality 
and  the  electric  sensibility  are  concerned.  Certainly  in  most  cases  there  is  no 
excessive  sensibility  to  ])ressure,  and  indeed  commonly  the  pain  is  more  or  less 
distinctly  relieved  by  firm  pressure.  There  is  usually  no  tenderness  either 
during  or  after  the  attack  at  the  point  of  emergence  of  the  nerve  from  the 
bone,  although  in  some  cases  a  certain  degree  of  general  tenderness  of  the 
face  is  produced  by  a  violent  paroxysm.  A  remarkable  but  very  rare  com- 
plication of  migraine  is  an  aphasia  coming  on  during  the  height  of  the  attack. 


SLEEP:    ITS   DTSORDERS   AND    ACCIDENTS.  659 

It  does  not  seem  worth  while  to  discuss  the  iiunierous  theories  which 
have  been  brought  forward  as  explanatory  of  migraine.  The  paroxysms  are 
evidently  of  the  nature  of  nerve-storms.  Trousseau  many  years  ago  callotl 
attention  to  the  relations  of  epilepsy  and  migraine,  and  cases  do  occasionally 
occur  in  which  the  migraine  and  epilepsy  coexist,  or  even  in  which  one  seems 
to  replace  the  other.  In  the  vast  majority  of  cases,  however,  no  relation  can 
be  traced  between  the  two  disorders.  Much  more  definite,  though  very  obscure, 
seem  to  be  the  relations  between  migraine,  gout,  and  hay  fever. 

iNIigraine  is  to  be  recognized  by  its  paroxysmal  occurrence,  by  the  almost 
invariable  history  of  inheritance  which  accompanies  it,  and  by  the  absence  of 
other  causes  for  the  headache.  Relief  from  the  paroxysm  can  often  be  obtained 
bv  the  use  of  antipyrin,  phenacetin,  and  caifeine  alone  or  in  various  combina- 
tions, taken  during  the  prodromic  stage.  Most  migraine  subjects  bear  opium 
badlv,  but  the  combination  of  deodorized  tincture  of  opium  and  the  bro- 
mide of  potassium  in  proportionate  doses  (TTLxx  to  gr.  xlv)  almost  invariably 
gives  relief  without  causing  narcotism  or  vomiting.  Of  course  great  care  is 
necessary  to  avoid  the  production  of  the  opium-habit. 

In  the  general  treatment  of  the  disorder  it  must  be  remembered  that, 
while  migraine  cannot  be  cured,  the  nerve-storms  become  infrequent  during 
high  health,  and  that  between  the  attacks  care  must  be  taken  to  build  up  the 
patient  and  to  correct  gouty  or  other  disease  tendencies.  The  continuous,  pro- 
longed administration  of  the  extract  of  cannabis  Indica,  in  dose  just  insufficient 
to  produce  physiological  effect,  has  in  many  cases  of  migraine  great  influence 
in  abating  the  number  and  severity  of  the  paroxysms.  Pcrijihcral  irritations, 
such  as  eye-strain,  may  greatly  aggravate  the  disorder,  and  must  be  carefully 

prevented. 

Sleep:   its  Disorders  and  Accidents. 

Led  chiefly  by  theoretical  considerations,  some  neurologists  have  dis- 
tinguished sleep,  stupor,  and  coma  as  essentially  diverse  conditions,  readily 
to  be  diagnosed  in  the  sick-room.  These  states  are,  however,  simply  the  out- 
come of  different  degrees  of  completeness  in  the  suspension  of  the  functions  of 
the  cerebral  cortex,  and  are  not  separated  by  any  fixed  lines.  Nor  is  the  uncon- 
sciousness of  anesthesia  an  isolated  thing:  it  is  simply  a  suspension  of  cere- 
bral function  in  which  a  known  chemical  agent  is  the  cause  of  the  paralysis. 
Although  in  the  sick-room  every  grade  can  be  found  between  light  and  heavy 
siinnber,  between  heavy  sleep  and  stupor,  and  between  stujM)!-  and  coma,  yet 
for  discussion  we  may  arbitrarily  separate  them  :  nlecp,  that  condition  of  unc«)n- 
sciousness  in  which  the  subject  is  readily  aroused,  and  when  aroused  is  easily 
kept  awake  by  ordinary  external  stimulations  or  i)y  his  will-power  ;  .sfujx)!-, 
that  condition  in  which  the  subject  is  aroused  with  great  (lilliculty,  and  wIkmi 
left  to  liimself  relapses  into  imconsciousness ;  coma,  that  state  in  whi(;h  it  is 
impossibh;  i)v  external   irritation  to  restore  consciousness. 

It  seems  necessary  to  say  here  a  fi'W  words  in  regard  to  the  immediate 
causes  of  ]a])sea  of  consciousness,  since  certain  authorities  claim  that  they  are 
due  to  chan<res  in  the  (;irculation.     No  i)ro(.r  of  this  has,  howcv<T,  ever  been 


660  FUNCTIONAL    NERVOUS   DISEASES. 

given.  It  is  true  that  during  sleep  there  is  more  or  less  pronounced  cerebral 
aUcTmia,  which  on  awaking  is  replaced  by  turgescence  of  the  cerebral  vessels. 
It  is  a  universal  law  that  cessation  of  functional  activity  is  immediately  fol- 
lowed by  lessening  in  the  amount  of  blood  in  the  part.  I  conceive,  therefore, 
that  the  sleep  or  cessation  of  functional  activity  is  the  cause  of  the  blood- 
lessness,  and  not  the  bloodlessness  the  cause  of  the  slee]>.  Insomnia  may  be 
connected  either  with  excessive  anaemia  or  with  excessive  congestion  of  the 
cerebral  cortex.  The  best  explanation  of  sleep,  then,  is  that  when  exhausted 
bv  effort  the  cortical  brain-cells  pass  into  a  condition  of  functional  inactivity, 
during  which  their  power  of  further  effort  is  recuperated.  Because  conscious- 
ness is  the  expression  of  functional  activity  in  these  cells,  therefore  when  these 
cells  do  not  exercise  their  function  there  is  unconsciousness — i.  e.  sleep. 

In  treating  of  sleep  and  its  disorders  I  shall  divide  the  subject  into  three 
parts  :  first,  abnormal  wakefulness ;  second,  abnormal  somnolence,  or  morbid 
sleep ;  third,  accidents  or  groups  of  symptoms  which  occur  during  sleep,  and 
which  are  not  elsewhere  spoken  of  in  this  book. 

Abnormal  Wakefulness. — In  simple  insomnia  the  form  of  the  sleepless- 
ness varies.  In  some  instances  the  subject  is  simply  unable,  when  bedtime 
comes,  to  go  to  sleep.  In  other  cases  he  goes  to  sleep  readily,  but  in  the  course 
of  two  or  three  hours  wakes,  and  is  unable  to  slumber  again.  The  latter  form 
of  insomnia,  in  my  experience,  is  not  commonly  the  precursor  of  severe  mental 
affection,  but  is  often  obstinate. 

Insonmia  may  be  prodromic  of  various  diseases  of  the  brain.  It  is  very 
common  in  the  insanities.  It  is  also  present  not  rarely  in  such  general  organic 
brain  diseases  as  general  paralysis  of  the  insane,  but  is  seldom  a  symptom  of 
tumor  or  other  focal  brain-lesion.  It  may  be  produced  by  various  diseases  of 
organs  other  than  the  cerebrum.  It  may  exist,  however,  in  its  most  aggra- 
vated form  without  other  evidences  of  cerebral  disturbance,  and  in  some  cases 
cerebral  exhaustion,  and  even  more  severe  mental  symptoms,  are  without 
doubt  produced  by  the  loss  of  sleep.  The  diagnosis  of  the  cause  of  an  insom- 
nia is  to  be  made  by  exclusion.  If  other  symptoms  of  cerebral  disease  are 
wanting,  the  condition  of  the  heart  and  kidneys  should  be  carefully  examined, 
because  latent  disease  of  these  organs  occasionally  has  sleeplessness  for  its  chief 
manifestation.  When  no  disease  of  the  brain  or  other  portions  of  the  organ- 
ism can  be  made  out,  the  diagnosis  of  simple  or  functional  insomnia  must  be 
settled  upon. 

The  treatment  of  insomnia  requires  much  tact,  and  at  best  is  often  very 
unsuccessful.  The  foundation  of  it  consists  in  the  removal  of  the  condition 
which  is  the  cause  of  the  insomnia.  If  the  wakefulness  be  lithsemic,  anti- 
gout  treatment  must  be  instituted;  if  it  be  due  to  a  local  or  general  neuras- 
thenia, this  must  be  combated. 

In  rare  cases  of  active  determination  of  blood  to  the  head  local  abstrac- 
tion of  blood  may  be  required.  More  commonly  insomnia  seems  to  be 
connected  with  exhaustion  ;  at  least  it  is  not  infrequent  to  find  that  food  taken 
at  bedtime,  or  when  the  patient  wakes  sleepless-in  the  middle  of  the  night,  has 


SLEEP:    ITS   DISORDERS    A  XD    ACCIDENTS.  661 

a  very  beneficial  eifect.  This  food  usually  acts  best  when  it  is  iiot  and  easily 
digestible.  Bcjuilloii  thickened  with  some  nutritive  starchy  material,  oyster 
soup,  milk  punch  warm,  liave  often  been  found  serviceable.  Alcohol  in  the 
form  of  whiskey  or  brandy,  taken  with  a  little  hot  water,  is  often  efficient. 
It  may  well  be  that  in  these  cases  the  good  is  achieved  by  stimulating  the 
stomach  and  drawing  excitement,  nervous  and  arterial,  from  the  brain.  Cer- 
tainly midnight  wakefulness  may  sometimes  be  overcome  by  a  single  glass 
of  hot  water  taken  in  the  middle  of  the  nioht. 

In  some  patients  massage  taken  just  before  the  time  of  sleep  has  a  distinct 
quieting  influence,  whilst  upon  others  it  acts  as  an  excitant.  A  procedure 
which  I  have  seen  act  very  happily  in  insomnia  with  active  congestion  of  the 
brain  is  to  allow  the  jxitient  to  sit  in  a  bath  of  very  hot  water  and  have  a  cold 
douche  on  the  head  from  three  to  five  minutes.  The  effects  of  exercise  vary 
in  different  individuals,  and  the  amount  ordered  must  be  judged  of  by  the 
result.  In  neurasthenic  insomnia  tire  usually  causes  wakeful  nights.  In 
most  cases  of  insomnia  it  is  essential  that  intellectual  activity  and  emotional 
excitement  during  the  latter  third  of  the  day  be  avoided  ;  that  the  suj>per 
taken  be  light ;  that  the  patient  sleep  by  himself  or  herself  in  a  well-venti- 
lated apartment ;  and  that  no  catfeinic  drinks  be  used  after  the  morning 
meal. 

The  treatment  of  insomnia  by  drugs  is  always  to  be  avoided  as  much  as 
])ossible.  In  some  cases,  however,  these  agents  have  to  be  employed,  and 
sometimes  it  is  possible  by  making  a  strong  nightly  influence  for  a  few 
weeks  to  break  up  the  habit  of  insomnia  and  then  gradually  to  withdraw  the 
remedy.  Hypnotic  remedies  are  numerous,  and  in  long-continued  insomnia 
it  is  better  to  periodically  change  them.  Sul phonal  has  seemed  to  me  the 
least  harmful,  though  by  no  means  the  most  certain  of  the  class.  It  should 
always  be  given  in  the  form  of  the  powder  about  an  hour  before  the  expected 
time  of  sleep.  The  compressed  pill  of  sulphonal,  so  much  used,  very  fre- 
(piently  passes  through  the  intestines  without  change.  Chloral  still  remains 
the  most  efficient  remedy  of  the  class.  Chloralamide  has  some  virtue,  but  is 
uncertain.  Urethan  seems  to  be  even  less  active,  whilst  paraldehyde  is  so  dis- 
agreeable and  irritating  to  the  stomach  that  it  is  only  to  be  employed  on  rare 
occasions.  Except  in  the  case  of  old  })eople  opiates  are  to  be  avoided  for  fear 
of  producing  a  narcotic  habit. 

Morbid  Si>eep. — INIorbid  somnolence  may  be  due  to  an  almost  infinite 
number  of  causes,  including  various  acute  diseases  and  poisonings.  As  almost 
all  of  these  affections  have  been  sufficiently  descril)cd  in  this  work,  it  only  re- 
mains to  say  a  word  in  regard  to  the  so-called  "  Xc/(ir((n"  Afrlccni  Iii/piiosis, 
or  African  fileepinr/  dlfirase,  an  acute,  very  fatal  fever,  the  most  characteristic 
symptom  of  whicth  is  excessive  somnolence.  It  is  endemic  on  the  west  coast 
of  Africa,  but  ap])ears  to  occur  e])idemically  in  some  (»f  the  West  India  Islands. 
It  attacks  tlie  negroes  especially,  but  has  in  a  inunber  (•("  instances  d(>cimated 
regiments  of  French  troops.  In  most  cases  i(  comes  on  gradually,  but  it  may 
begin  brusquely.     There  is  at  first  a  slight  frontal  headache,  with  a  sense  of 


fifi2  FUyvTloyAL    NERVOUS   DISEASES. 

constriction  in  the  forehead,  attended  by  a  mild  fever.  The  vision  may  at  this 
period  be  disordered.  The  gait  becomes  irregular,  and  not  very  infrequently 
there  is  a  distinct  ataxia.  Even  during  the  first  hours  of  the  headache  an 
intense  desire  for  sleep  is  manifested.  This  continually  increases  until  the 
j)atient  is  overpowered  by  an  irresistible  somnolence.  During  the  period  of 
sleepiness  the  strength  fails,  the  spirits  are  depressed,  and  there  is  some  fever, 
but  usually  neither  diarrhoea  nor  constipation  develops,  and  the  forces  of  the 
circulation  are  well  maintained.  The  somnolence  when  once  developed  con- 
tinues to  become  more  and  more  intense,  and  the  patient  gradually  sinks  into 
a  profound  coma,  which  may  pass  quietly  into  death  :  violent  convulsions  and 
sloughing  bedsores  are  liable  to  develop.  There  are  no  pathognomonic  post- 
morten  lesions  unless  it  be  swelling  of  the  glands. 

Omitting  toxsemic  somnolence,  most  of  the  cases  of  morbid  sleep  seem  to 
be  referable  to  one  of  five  groups: 

Group  1.  Sleep  due  to  reflex  irritations. 

Group  2.  Narcolepsy,  or  idiopathic  sleep  of  unknown  cause. 

Group  3.  Hysterical  and  epileptic  sleep. 

Group  4.  Sleep  of  insanity. 

Group  5.  Somnolence  connected  with  organic  brain  disease. 

Of  the  third  and  fifth  of  these  groups  sufficient  has  already  been  said. 
(For  Group  4  see  article  on  Mental  Disease.)  Reflex  sleep  is  very  rare,  but 
Dr.  Katerbau  has  recorded  a  case  in  which  a  seventeen-year-old  Jewess,  who 
had  slept  four  days  and  nights,  immediately  awoke  after  the  jiassage  from  the 
rectum  of  a  knot  containing;  twentv-four  round-worms,  whilst  Dr.  Maver  has 
related  a  similar  case  of  a  boy  nine  years  old. 

Narcolepsy. — The  cases  of  morbid  sleep  which  are  here  grouped  together 
under  the  name  of  narcolepsy  vary  in  the  intensity  of  their  symptoms  from 
drowsiness  to  a  sleep  which  ends  in  death.  It  is  most  probable  that  the  cause 
of  the  sleep  varies,  and  that  several  distinct  affections  are  represented  in  the 
group,  and  that  some  of  the  recorded  cases  have  also  been  instances  of  hys- 
terical or  orgam'c  disease.  The  best  that  can  be  done  at  present  is  to  separate 
the  cases  into  three  subgrou])s,  which  are  not  very  clearly  distinguishable,  and 
indeed  are  probably  closely  connected  by  intermediate  cases.  In  the  first  of 
these  groups  the  subject  passes  many  hours  in  what  seems  to  be  the  ordinary 
slumber.  In  some  cases  the  sleep  comes  on  daily,  in  others  at  longer  inter- 
vals. In  some  instances  there  is  a  perpetual  drowsiness,  in  others  the  patient 
when  awake  is  not  sleepy. 

The  second  class  of  cases  com])rises  those  in  which  the  paroxysms  of  sleep 
come  on  at  irregular  intervals  and  continue  for  days,  as  in  a  Jewess  who 
shortly  after  her  marriage  fell  into  a  prolonged  sleep  which  ever  afterward 
recurred  periodically.  The  average  length  of  the  sleeping  period  was  five  and 
a  half  days,  the  longest  time  that  she  had  ever  slept  being  seven  days.  The 
intervals  of  wakefulness  lasted  from  two  to  twenty  days,  during  which  time 
she  did  not  sleep  at  all  or  had  only  a  very  little  restless  slumber. 

A  third  class  of  cases  is  that  in  which  the  sleep  comes  on  without  apparent 


SLEEP:    ITS  DISORDERS  AND    ACCIDENTS.  663 

cause,  and  becomes  more  and  more  profound  until  the  patient  dies.  These 
cases  as  recorded  seem  to  have  been  due  to  brain  congestion,  and  some  have 
yielded  to  very  free  venesection.  Other  cases  have  been  instances  of  cerebral 
organic  disease,  but  there  remain  cases  like  that  reported  by  Dr.  S.  Weir 
Mitchell,  in  which  death  after  a  prolonged  seemingly  causeless  sleep  has 
resulted,  and  in  which  a  most  careful  post-mortem  examination  has  failed  to 
detect  any  lesion. 

Accidents  of  Sleep. — Sense-shock,  so  called,  occurs  in  hysterical  M'omen 
and  overworked  men,  usually  whilst  passing  from  sleep  to  waking.  A  sensa- 
tion like  an  aura  rises  from  the  feet — or,  more  rarely,  from  the  hands — and 
passes  upward  to  the  head,  where  it  disappears  in  the  sense  of  a  blow  or  shock 
or  of  a  bursting  in  the  head.  Not  rarely  at  the  time  of  the  explosion  the 
patient  hears  a  loud  noise  or  sees  a  vivid  flash  of  light  or  perceives  a  strong 
odor.  In  some  cases  two  or  even  more  of  these  sensory  manifestations  are 
present  together.  The  paroxysm  may  occur  during  the  daytime.  These 
attacks  have  no  serious  significance,  and  there  is  no  special  treatment. 

Night  Palsy  consists  simply  of  a  feeling  of  numbness  in  one  or  more  extrem- 
ities of  the  body  when  the  sleeper  awakes.  The  most  common  seat  is  one  arm, 
but  the  symptom  may  be  hemiplegic  or  may  affect  the  whole  body.  I  have 
seen  it  in  hysterical  women,  especially  after  the  climacteric.  Dr.  S.  Weir 
Mitchell  speaks  of  it  as  occurring  in  locomotor  ataxia.  It  is  certainly  not 
indicative  of  failure  of  the  circulation,  and  seems  indeed  to  have  no  especial 
significance. 

Somnambu/lsm. — Somnambulism  is  defined  by  Dr.  H.  Barth'  to  be  a  dream 
with  exaltation  of  the  memory  and  of  the  automatic  activity  of  the  nerve- 
centres,  combined  with  absence  of  consciousness  and  spontaneous  will.  It  is 
common  for  a  sleeper  to  give  evidence  of  his  thoughts  by  movements  and  mut- 
tered words  :  a  step  beyond  tliis  and  the  dreamer  acts.  Every  grade  between 
the  slightest  dream-movement  and  the  most  active  sleep-walking  exists ;  but 
whenever  a  dreamer  rises  from  his  couch  he  mav  be  said  to  be  a  somnam- 
bulist. 

If  the  somnambulist  be  ajjproached,  his  eyes  will  be  found  to  be  closed,  or, 
if  open,  they,  with  the  rest  of  the  face,  are  impassive  and  without  expression, 
paying  no  attention  to  the  brightest  lights,  and  appearing  to  have  no  ])ower  of 
sight  in  them  ;  yet  obstacles  are  avoided,  narrow  places  passed  through,  feats 
of  balancing  performed,  and  numerous  complicated  movements  made  so  per- 
fectly that  the  bystander  can  hardly  persuade  himself  that  the  sleej^er  is  not 
awake.  When  seized  hold  of,  the  somnambulist  usually  resists  with  vigor. 
Left  to  himself,  after  wandering  for  a  greater  or  less  length  of  time  he  returns 
to  his  bed,  covers  himself  up,  and  sinks  into  the  quiet  ibrgetfulness  of  noruuil 
sleejx 

In  the  milder  forms  of  soinuambulisin  it  is  sometimes  possible  to  turn  the 
thoughts  of  the  sleeper  by  speaking  to  hiui,  and  in  obedience  to  a  firm  com- 
mand he  will  return  to  his  bed  without  waking.     Acts  the  most  dillicult  and 

'  Du  Sommcil  non-nalurel,  Paris,  1880. 


\ 


664  FUXCTIOXAL    NERVOUS  DISEASES. 

complicated  are  often  pertbrined  by  the  somnambulist,  and  even  murder  has 
been  done  in  obedience  to  the  impulse  of  the  dream. 

The  so-called  night-terrors  of  childhood,  although  frequently  spoken  of  as 
a  distinct  affection,  are,  in  truth,  only  a  form  of  somnambulism,  or,  in  rare 
cases,  epileptoid  seizures.  Nothing  is  more  common  than  for  a  young  child  to 
go  in  the  night  to  its  parent's  bed,  trembling  with  terror  or  weeping  bitterly, 
with  the  statement  that  it  has  had  a  bad  dream.  Such  a  dream  may  be  so 
vivid  as  completely  to  enchain  the  attention,  and  if  at  the  same  time  there  be 
outward  manifestations  of  the  overpowering  emotions  from  which  the  child  is 
suffering,  a  paroxysm  of  night-terror  results.  Very  frequently  during  the 
paroxysm  the  child  shows  terror  of  some  one  object — a  cat,  a  dog,  a  white  ele- 
phant, a  monster  of  some  kind,  is  indicated  by  its  incoherent  cries.  In  a  large 
majority  of  cases  night-terrors  are  of  no  more  serious  import  than  an  attack 
of  somnambulism.  They  often  depend  upon  gastric  irritation  or  too  much 
emotional  excitement  during  the  day.  In  a  few  recorded  eases  the  cause  of 
the  attacks  has  been  intestinal  wornis.  Those  rare  night-terrors  which  are  due 
to  serious  disease  can  only  be  distinguished  by  their  tendency  to  continually 
recur  and  by  their  concomitant  symptoms. 

I  have  seen  one  or  two  cases  of  night-terrors  occurring  in  adults  which  by 
their  frequency  and  severity  absolutely  destroyed  the  usefulness  of  life,  and 
were  not  removed  by  any  of  the  innumerable  treatments  instituted  by  various 
physicians.  It  is  stated  that  the  habit  of  somnambulism  can  sometimes  be 
broken  up  by  sutldenly  awaking  the  patient  with  a  shock. 

The  ircneral  treatment  must  be  that  of  neurasthenia  and  hysteria.  In  the 
case  of  night-terrors  of  children  special  care  should  be  taken  to  remove  intes- 
tinal worms,  glandular  swellings,  or  any  other  possible  source  of  local  irrita- 
tion. The  use  of  stimulating  foods  and  of  caffeinic  drinks  must  be  avoided, 
and  only  light  suppers  should  be  allowed. 


Correlated  Disorders  op  Memory  and  Consciousness. 

All  functional  acts  are  accompanied  by,  or  dependent  u[)on,  a  nutritive  dis- 
turbance. It  matters  not  whether  the  functional  act  be  connected  with  thought, 
consciousness,  or  secretion,  the  generation  of  nerve- force  by  the  ganglionic  cell 
and  its  transmission  by  nerve-fibre  are  accompanied  by  nutritive  changes  in 
these  bodies.  A  nutritve  act,  although  temporary,  has  a  distinct  tendency 
to  impress  permanently  the  part  implicated;  and  this  tendency  is  especially 
pronounced  in  nervous  tissue.  All  nervous  tissue  is,  therefore,  liable  to  be 
permanently  affected  by  its  own  functional  actions.  This,  it  must  be  remem- 
bered, applies  e([ually  to  normal  and  to  pathological  activities.  Thus,  the  child 
in  learning  to  walk  by  repeated  efforts  trains  the  lower  nerve-centres  until,  in 
response  to  ai)propriate  stimuli,  a  definite  series  of  nervous  discharges  and 
transmissions  occur  independently  of  the  will,  and  walking  becomes  automatic. 
This,  in  short,  is  the  history  ol'  all  training,  mental  and  physical.  All  nerv- 
ous tissues    therefore,  have  memory — l.  e.  the  faculty  of  being  permanently 


DISORDERS    OF  MEMORY   AXD    CONSCIOUSNESS.  6G5 

impressed  by  temporarily  actiiiij;  .stimuli,  the  tliino-  remembered  being,  in  fact, 
the  funetional  excitement. 

The  recognition  of  the  universality  of  memory  in  nerve-tissues  is  of  great 
importance  in  the  consideration  and  treatment  of  disease.  Thus,  an  epileptic 
fit  is  produced  by  a  peripheral  irritation.  If  that  peripheral  irritation  be  at 
once  removed,  the  fit  does  not  recur  and  the  patient  is  cured.  If,  however, 
the  irritation  be  not  soon  taken  away,  but  produces  a  series  of  convulsions, 
the  fits  may  continue  after  the  removal  of  the  irritation,  simply  because  of  the 
permanent  impress  which  has  been  made  upon  those  cells  in  the  brain-cortex, 
whose  discharge  of  nerve-force  is  the  immediate  cause  of  the  epileptic  parox- 
vsm.  The  nutrition  of  the  cells  has  been  so  altered  that  at  irregular  intervals 
they  fill  up  and  discharge  nerve-force. 

Owing  to  this  power  of  memory  a  physical  habit  may  become  so  perma- 
nently engrafted  uj^on  the  nervous  system  that  the  jiatient  is  unable  to  control 
it.  An  example  of  this  is  seen  in  the  so-called  habit  choreas  :  movements  at 
first  controllable,  mere  bad  habits,  become  at  last  fixed,  not  to  be  altered  by 
any  power.  The  hysterical  woman  who  gives  way  to  hysterical  nervous 
impulses  thereby  strengthens  their  hold  upon  the  system,  so  that  in  time  she 
may  lose  all  power  of  control  over  the  lower  nerve-centres.  Moral  habits  are 
formed  in  obedience  to  the  same  law.  Self-control,  enforced  at  first  by  dis- 
cipline, may  become  at  last  in  the  child  an  integral  function  of  the  nervous 
centre  by  a  method  parallel  to  that  by  which  an  accidental  epilepsy  is  converted 
into  a  permanent  disease.  In  the  prognosis  and  treatment  of  disease,  as  well 
as  in  the  training  of  the  young,  the  full  recognition  of  the  power  of  habit — /.  e. 
of  unconscious  memory — is  a  matter  of  vital  importance. 

What  is  true  of  the  lower  nerve-centres  and  fibres  is  true  of  the  upper  ones. 
Intellectual  acts  or  thoughts  and  perceptions  tend  to  stamp  themselves  upon 
the  centres  connected  with  them,  and  when  the  function  of  the  nerve-cell  is 
connected  with  conscioiisness  the  changes  which  occur  in  the  nutrition  give 
oriirin  to  conscious  memory — /.  e.  to  memorv  in  the  usual  sense  of  the  term. 

The  methods  of  ordinary  mental  action  seem  to  indicate  either  that  special 
ganglionic  cells  are  set  apart  for  special  forms  of  memory,  or  else  that  the 
sintrle  <rantrlionic  cell  is  capable  of  distinct  acts  of  memorv.  Thus,  one  indi- 
vidual  will  rememljcr  one  class  of  facts  with  great  ease,  to  the  exclusion  of 
f)ther  matters,  whilst  the  second  person  may  readily  remember  those  affairs 
which  the  first  naturally  forgets.  Disease  sometimes  dissects  out,  as  it  were, 
the  different  forms  of  memory,  isolating  one  from  the  other.  It  is  well  known 
that  in  the  loss  of  memoi-y  which  accompanies  senile  changes  of  the  brain 
or  is  a  prominent  sym|)tom  in  the  first  stage  of  general  paresis  the  power  of 
rememljcrin*'-  recent  events  ma\'  be  lost,  although  the  i-ecollectiou  ol"  all'airs 
which  ha])pened  in  childhood  days  is  far  more  vivid  than  in  the  norinal  con- 
dition of  the  individual.  Under  these  circumstances  it  may  be  considered  that 
the  ganglionic  cells  have  lost  their  cajjability  *>l'  receiving  impressions,  but  not 
that  of  recognizing  impressions  which  were  made  long  before.  The  sepai-atiou 
of  different  forms  of  memory  is,  however,  distinct  from  this.     Thus  in  a  case 


666  FUNCTIONAL    NERVOUS   DISEASES. 

of  dementia  recently  under  my  care  memory  for  ordinary  events  was  almost 
entirely  lost,  and  yet  a  joke  or  a  ludicrous  story  would  be  remembered  in  all 
its  details  without  ajiparent  effort.  It  is  well  established  that  one  form  of 
memory — namely,  that  connected  with  language — has  in  most  individuals  a 
definite  brain-location  ;  and  it  may  be  that  each  variety  of  memory  has  its 
own  territory. 

In  considering  the  disorders  of  memory  I  shall  omit  the  discussion  of  dis- 
turbances of  specialized  forms  of  memory,  because  the  most  important  of  these, 
aphasia,  will  be  elsewhere  fully  elucidated  by  Professor  Osier.     (See  page  701.) 

Failure  of  Memory  is  a  frequent  symptom,  which,  when  not  due  to 
obvious  acute  disease,  is  a  strong  indication  of  an  organic  affection  of  the 
brain,  although  a  slight  degree  of  it  may  be  produced  by  simple  brain- 
exhaustion.  In  some  cases  careful  examination  is  needed  to  detect  it.  Under 
such  circumstances  the  physician  must  question  the  patient  as  to  the  small 
events  of  the  last  twenty-four  hours,  and  not  be  misled  by  that  vividness 
of  recollection  of  the  long  past  which  sometimes  causes  the  sufferer  to  declare 
that  his  memory  is  even  stronger  than  normal.  It  is  evident  that  what  is 
first  lost  is  not  the  power  of  recalling  impressions  already  made,  but  of 
receiving  or  taking  new  impressions.  Old  impressions  come  readily  into  the 
scope  of  consciousness,  but  passing  events  leave  no  stamp  upon  the  brain-cells. 
In  doubtful  cases  of  general  paralysis  of  the  insane  failure  of  memory  is  of 
special  value  in  enabling  us  to  distinguish  the  organic  insanity  from  functional 
mental  disturbances  which  may  simulate  it.  According  to  my  own  experience, 
failure  of  memory  which  is  not  accompanied  by  paralysis  for  the  time  being 
of  all  the  functions  of  the  mind,  as  in  insanity,  is  of  serious  import  in  propor- 
tion to  its  completeness. 

True  Exaltation  of  Memory — i.  e.  exaggeration  of  the  power  of 
receiving  new  impressions  or  acquiring  new  facts — is  a  rare  phenomenon, 
which  nuist  be  sharply  distinguished  from  the  peculiar  exaggeration  of  recol- 
lection spoken  of  in  the  next  paragraph.  It  is  sometimes  present  in  the 
insomnia  due  to  exaltation  of  the  cerebral  cortex,  Avhen  it  is  an  extremely 
alarming  symptom.  Cases  are  also  on  record  in  which  it  has  preceded  an 
attack  of  apoplexy  or  even  of  general  paralysis. 

As  has  already  been  stated,  a  memory  is  possessed  by  all  varieties  of  gan- 
glionic nerve-cells,  but  that  intellectual  function  to  which  the  name  is  usually 
restricted  is  so  closely  related  with  consciousness  that  we  can  scarcely  conceive 
of  its  existence  without  consciousness  ;  nevertheless,  the  connection  of  memory 
with  dreaming  shows  that  it  is  a  separate  function  from  consciousness. 

There  are  a  good  many  reasons  for  beliving  that  the  impressions  of  all 
events  with  which  an  individual  has  been  connected  are  indelibly  recorded 
upon  his  brain-tissue,  although  he  may  not  be  able  to  bring  such  impressions 
into  conscious  perception.  At  the  approach  of  death  or  under  the  stimulation 
of  disease  at  a  time  when  consciousness  is  wanting  persons  will  frequently 
sj)eak  in  foreign  tongjies,  recite  passages  of  prose  or  poetry  long  since  forgot- 
ten, or  give  detailed  accounts  of  events  that  occurred  in  their  earliest  child- 


DISORDERS    OF  MEMORY  AND    CONSCIOUSNESS.  007 

hood,  and  of  wliicli  they  have  in  tlieir  normal  condition  not  tlie  slightest 
remembrance.  It  would  therefore  appear  that  two  distinct  functions  or  acts 
are  involved  in  conscious  memory — one  the  preservation  of  the  records,  th<' 
other  the  dragging  out  of  such  records  into  the  light  of  consciousness  and 
their  recognition  by  the  personality  of  the  man.  In  certain  diseases  when 
consciousness  is  obliterated  the  connection  between  the  stored  records  of  the 
cerebral  cortex  and  the  automatic  speech-centres  is  so  close  that  the  hitter  act 
in  obedience  to  the  records,  and  the  unconscious  patient  speaks  in  an  unknown 
tongue  or  relates  occurrences  of  which  he  has  no  conscious  mcmorv. 

When  the  link  that  binds  consciousness  to  memory  is  broken  by  disease 
consciousness  may  exist  without  memory.  Under  these  circumstances  con- 
sciousness is  isolated  from  the  past,  although  the  past  may  still  be  connected 
with  the  present  by  an  automatic  unconscious  memory.  This  is  illustrated  bv 
the  famous  case  of  the  French  soldier,  who,  as  the  result  of  a  wound  in  the 
head,  was  subject  to  attacks  lasting  many  hours  in  which  he  had  no  sensitive- 
ness of  any  part,  although  if  put  in  the  position  of  marching  or  writing  or 
smoking,  etc.  he  would  go  through  the  whole  complicated  series  of  acts  neces- 
sary for  the  performance  of  these  acts,  all  of  the  time  evidently  unconscious 
of  what  he  was  doing  and  changing  from  one  performance  to  another  as  he  was 
taken  hold  of  and  put  into  a  new  position. 

The  sense  of  personal  identity  is  dependent  upon  the  existence  of  memory 
and  consciousness.  The  unbroken  chain  of  events  recorded  from  an  indefinite 
past  correlated  with  the  consciousness  of  the  present  gives  the  realization  of 
the  unity  of  the  jiresent  with  the  past.  This  sense  of  personal  identity  is 
destroyed  by  a  complete  loss  of  memory,  which  loss  may  be  abrupt  and  be 
unaccompanied  by  impairment  of  consciousness  or  of  rationality.  I  have 
seen  tiiis  association  of  symptoms  continue  for  several  days  after  a  sunstroke, 
so  that  the  patient,  who  had  been  brought  by  ambulance  into  the  hospital,  was 
unable,  after  he  had  recovered  his  mental  faculties  and  was  perfectly  rational, 
to  give  any  clue  to  his  personality  which  could  lead  to  his  identification. 

Double  Personality,  the  condition  in  which  the  subject  feels  as  il"  ho  were 
two  distinct  personalities,  the  one  alternating  continually  with  the  other,  has 
no  connection  with  loss  of  personal  identity  nor  yet  with  double  consciousness. 
Its  explanation  is  very  difficult :  it  is  occasionally  seen  as  the  result  of  hash- 
eesh or  other  poisonings,  and  also  in  insanity,  in  which  affection  it  may  become 
the  basis  of  a  delusion,  as  in  the  case  of  a  patient  of  my  own  w  ho  was  over- 
whelmed by  the  constant  doubt  whethci-  he  was  himself  or  his  own  double. 

Double  Consciousness,  so  called — periodical  failure  of  memory,  or  periodic 
amnesia — is  a  disorder  of  memory  which  also  involves  all  the  intellectual  func- 
tions and  the  character  of  the  individual.  In  a  typical  case  there  is,  first,  an 
abrupt  loss  of  memory  at  the  beginning  of  each  paroxysm  for  everything  that 
has  liappencd  during  paroxysms  not  of  the  same  series  ;  second,  a  diaugc  in 
the  personal  character  of  the  indivi<lual,  fii(!  disposition,  the  habits  of  llidught, 
and  even  the  intellectual  powers,  being  altered.  As  illustrating  this  condition 
may  be  mentioned  the  remarkal)l('  case  recorded   by  Dr.  Azam,  in  which   the 


668  FUNCTIONAL    NERVOUS  DISEASES. 

change  between  the  two  conditions  always  was  preceded  by  a  profound  sleep 
lasting  three  or  four  minutes,  during  which  time  a  complete  alteration  in  the 
character  of  the  girl  occurred.  In  state  No.  1  she  was  usually  more  or  less 
depressed,  very  quiet,  modest,  retiring  in  character,  and  of  only  moderate 
mental  power.  During  state  No.  2  she  was  gay,  vivacious,  without  any  evi- 
dences of  mental  aberration,  but  with  her  intellectual  faculties  much  more 
developed  than  during  her  normal  condition,  whilst  her  moral  state  was  such 
that  she  became  in  one  of  her  abnormal  periods  pregnant — a  condition  which 
overwhelmed  her  with  surprise  and  shame  when  she  was  finally  made  to 
understand  her  condition  during  a  No.  1  state,  at  which  time  she  had  no 
recollection  when  or  where  pregnancy  was  produced. 

I  have  seen  double  consciousness  caused  by  a  blow  upon  the  head,  and 
subsequently  removed  by  the  raising  of  the  depressed  fracture — a  fact  that 
indicates  (what  is,  indeed,  otherwise  very  apparent)  that  the  condition  allies 
itself  very  closely  to  the  automatism  of  epilepsy,  and  also  to  the  changes  in 
character,  mental  and  psychical,  seen  in  insanity.  Epileptiform  automatism 
may,  indeed,  be  considered  to  be  a  form  of  double  consciousness. 

I  have  seen  melancholia  come  and  go  in  transitory  attacks  of  a  few  hours 
or  days,  during  which  the  habits  of  thought,  the  intellectual  powers  of  the 
patient,  were  absolutely  abnormal,  and  Dr.  David  Skae  has  put  on  record  a 
case  of  a  man  who  lived  for  many  years  a  twofold  life,  being  sane  only  on 
alternate  days.  On  his  melancholy  days  he  neither  ate,  slept,  nor  walked,  but 
sat  incessantly  turning  the  leaves  of  the  Bible  and  complaining  piteously  of 
his  misery.  At  such  periods  he  had  no  remembrance  of  the  days  in  which  he 
was  well,  and  could  not  be  made  to  recognize  the  existence  of  well  days.  On 
the  well  day  he  denied  that  he  had  any  cause  of  complaint,  believed  that  he 
had  been  well  the  previous  day,  transacted  business,  and  was  entirely  free 
from  delusions  or  despondency.^ 

'  Double  consciousness  must  not  be  confounded  with  the  rare  mental  condition  known  by  the 
(iermans  as  double  perception  or  Doppeltwahrneluning,  in  which  ideas  received  through  one 
sense  become  to  the  man  reduplicated  over  and  over  again  through  the  same  or  another  sense. 
Thus,  in  a  certain  case  whenever  the  man  read  to  himself  he  would  plainly  hear  each  word 
repeated  as  though  a  chorus  of  fifty  or  sixty  female  voices  were  speaking  to  him,  and  when  he 
ceased  to  read  he  would  hear  the  last  words  read  after  him.  This  reading  after  him  disappeared 
as  soon  as  he  spoke  aloud,  and  was  prevented  by  his  reading  aloud.  Evidently  this  condition 
relates  itself  to  the  hallucinations  of  insanity. 


ORGANIC  DISEASES  OF  THE  BRAIN. 

By  WILLIAM  OSLER. 


I.  AFFECTIONS  OF  THE  MENINGES. 

Diseases  of  the  Dura  Mater. 

Pachymeningitis  Externa.— Inflammation  of  the  external  layer  of 
the  (Inra,  which  forms  the  periosteum  of  the  bones  of  the  skull,  usually 
follows  injury,  such  as  fracture,  and  is  accompanied  with  effusion  of  blood. 
Extension  of  inflammation,  as  from  erysipelas  of  the  seal}),  is  extremely  rare : 
more  commonly  it  follows  caries  of  the  bone,  as  in  sy])hilis  or  in  middle-ear 
disease.  In  these  cases  pus  may  collect  in  considerable  quantities  between  the 
dura  and  the  skull,  and  compress  the  brain  in  a  remarkable  manner.  The 
purulent  infiltration  may  extend  between  the  layers  of  the  dura  or  it  mav 
reach  the  inner  layer,  causing  a  suppurative  dura-arachnitis. 

The  symptoms  are  not  at  all  definite,  and  even  when  the  disease  is  exten- 
sive the  only  complaint  may  be  of  headache.  When  the  exudation  is  large, 
compression  symptoms  are  present — coma  with  or  without  paralysis.  In  cases 
of  caries  or  in  otitis  media,  if  an  external  purulent  pachymeningitis  be  sus- 
pected, the  trephine  should  be  used.  In  the  syphilitic  cases  there  may  be  a 
small  sinus  communicating  with  the  exterior. 

Pachymeningitis  Interna. — The  suppurative  form  is  rare,  and  is,  as  a 
rule,  a.ssociated  with  purulent  leptomeningitis.  Occasionally  there  is  a  pseudo- 
membranous formation,  an  in.^^tance  of  which  I  have  seen  in  pneumonia. 

H^:morriiagic  Pachymeningitis. — Tin's  condition,  M-hich  is  also  known 
as  hcematoma  of  the  dura  mater,  is  not  common  in  general  medical  practice, 
but  is  by  no  means  infrequent  in  asylums  and  almshouses :  thus,  Wiggles- 
worth  found  42  examples  in  a  series  of  400  unselected  post-mortems  in  asylum 
work.  The  affection  is  most  common  in  males  at  the  middle  ])erio(l  of  life,  in 
persons  addicted  to  alcohol,  and  in  lunatics.  It  has  been  met  with  also  in  the 
specific  fevers  and  in  profound  aujomia.  Cases  have  followed  injui-y  to  the 
head.  In  infants  it  is  occasionally  met  with,  and  is  said  to  have  followed 
whooping  cough. 

The  morbid  anatomy  and  patholog-y  have  been  nuicli  discussed.  A'^irchow, 
to  wh(jm  we  are  indebted  for  the  first  accurate  descrij)tioii,  regarded  it  as  a 
result  of  inflammation  of  tlu;  dura,  mihI  hcM  that  a  delicate  va.^cular  membi-anc 
preceded  the  clot.  In  a  majority  of  tlie  ca.ses  the  exudation  is  l)ilateral  and 
extends  over  tlie  dura  of  both  hemispheres,  and  in  very  extensive  cases  the 
membrane  extends  into  the  fos.'^se  at  the  base  of  the  skull.     Three  conditions 


670 


ORGANIC  DISEASES    OF    THE  BRAIN. 


are  seen  in  internal  pachymeningitis :  First,  subdural  membranes,  often  of 
extreme  delicacy,  with  large  wide-meshed  vessels.  There  may  be  no  hsemor- 
rhagic  exudation  whatever,  or  the  membrane  may  be  simply  stained  with  the 
blood-pigment.  Second,  there  are  instances  of  simple  subdural  hsemor- 
riiage  in  which  no  membrane  is  seen.  This  occurred  in  15  of  Wigglesworth's 
42  cases.  It  is  possible  that  the  haemorrhage  may  have  destroyed  all  traces 
of  the  membrane.  Third,  there  may  be  a  combination  of  the  two  vascular 
membranes  and  blood-clot.  In  some  cases  a  series  of  laminated  clots  exists, 
forming  lavers  of  from  two  to  three  millimetres  in  thickness,  between  which 
cysts  may  form.  It  is  stated  that  the  haemorrhage  occurs  first,  and  that  the 
vascular  sheet  arises  from  the  organization  of  the  blood-clot.  This  does  not 
appear  probable  when  one  considers  that  the  inner  surface  of  the  dura  may  be 
everywhere  covered  with  a  delicate,  highly  vascular  membrane,  without  a  trace 
of  staining  and  without  any  clot.  The  haemorrhage  is  thought  by  Hugenin  to 
proceed  from  the  vessels  of  the  pia  mater,  but  the  study  of  very  early  speci- 
mens is  convincing,  I  think,  in  favor  of  the  view  that  the  blood  comes  from 
the  wide  meshwork  of  vessels  in  the  new-formed  subdural  membranes.  The 
condition  is  usually  found  with  atrophy  of  the  convohitions,  and  it  is  stated 
that  this  perhaps  accounts  for  its  frequent  occurrence  in  the  insane;  but  there 
must  be  factors  other  than  atrophy,  or  we  should  find  it  more  frequently  in 
phthisis  and  cachectic  states,  in  which  the  cortical  w^asting  is  almost  as  marked 
as  in  insanity. 

The  symptoms  are  indefinite.  Extensive  haematoma  may  exist  without 
any  indications  during  life.  Headache,  somnolence,  contracted  pupils,  and 
optic  neuritis  have  been  described.  In  unilateral  disease,  when  extensive, 
hemiplegia  may  occur.  There  are  instances  in  which  the  symptoms  set  in 
abruptly  like  an  apoplectic  attack,  producing  loss  of  consciousness  and  some- 
times compression. 

The  diagnosis  is  always  doubtful. 


Diseases  of  the  Pia  Mater. 

Acute  meningitis  occurs  under  a  variety  of  conditions.  The  exudation  is 
beneath  the  arachnoid,  and  both  membranes  are  involved,  hence  the  term  pia- 
arachnitis.  A  common  designation  now  is  leptomeningitis.  The  exudate  is 
either  purulent  or  consists  of  a  sero-fibrinous  fluid  with  flakes  of  lymph. 

Various  forms  of  acute  meningitis  are  recognized,  such  as  (1)  tubercu- 
lous meningitis;  (2)  simple  meningitis;  (3)  leptomeningitis  infantum;  and 
epidemic  cerebro-spinal  meningitis,  which  is  elsewhere  considered. 

(1)  Tuberculous  Meningitis  (Acute  Hydrocephalus). 
This  occurs  as  a  secondary  affection  of  the  meninges  of  the  brain  and  cord, 
a  sequel,  as  a  rule,  to  a  local  tuberculous  disease  in  other  parts,  particularly  in 
the  lungs.  It  is  often  only  a  part  of  an  acute  general  tuberculosis.  It  is  most 
frequent  in  children,  i)articularly  between  the  ages  of  two  and  five.  In  some 
instances  blows  on  the  head,  falls,  and  overwork  have  preceded  the  onset.     In 


TUBERCULOUS  MEXINGITIS.  071 

almost  every  instance  there  is  coexistent  tuberculous  disease  in  other  parts, 
caseous  foci  in  the  lungs  or  in  the  bronchial  glands  (particularly  in  children), 
tuberculous  pleurisy,  or  bone  disease.  The  symptoms  may  develop  during 
convalescence  from  measles,  whooping  cough,  or  scarlet  fever. 

Morbid  Anatomy. — The  membranes  at  the  base  are  most  involved,  hence 
the  term  basilar  meningitis.  The  appearance  varies  greatly  in  different  cases, 
depending  a  good  deal  on  the  amount  of  inflammatory  exudate  existing  with 
the  tubercles.  As  a  rule,  the  Sylvian  fissures  and  the  interpeduncular  space 
are  most  involved.  There  may  be  only  slight  turbiditv  and  matting  of  the 
membranes,  which  are  moist  and  infiltrated.  In  other  instances  the  entire 
base  from  the  olfactory  bulbs  to  the  medulla  is  covered  with  a  fibrino-purulent 
exudate,  which  may  extend  to  the  lateral  surfaces  of  the  hemispheres,  but  is 
very  rarely  seen  upon  the  cortex.  It  often  extends  to  the  spinal  meninges. 
The  tubercles  may  stand  out  with  great  distinctness  as  grayish-white  nodules. 
In  some  instances  they  are  small  and  difficult  to  find.  The  amount  of  exudate 
does  not  bear  any  definite  proportion  to  the  number  of  tubercles.  They  should 
be  sought  for  along  the  branches  of  the  middle  cerebral  artery,  and  more  par- 
ticularly those  entering  the  perforated  spaces.  When  the  arteries  are  carefully 
withdrawn  and  spread  upon  a  glass  plate  upon  a  black  background,  the  tuber- 
cles are  seen  as  small  nodular  enlargements  of  the  vessels.  Histologically,  the 
new  growth  develops  in  the  perivascular  sheaths,  the  vessels  are  narrowed, 
and  thrombosis  not  infrequently  occurs.  The  lateral  ventricles  are,  as  a  rule, 
dilated  and  contain  an  excess  of  turbid  fluid.  The  epeudyma  is  sometimes 
swollen,  softened,  and  covered  with  exudate.  The  septum  lucidum  and  fornix 
are  usually  softened,  and  tubercles  are  sometimes  foimd  on  the  choroidal 
plexuses  and  in  the  velum.  The  contiguous  cerebral  substance  is  found  infil- 
trated and  oedematous.  There  may  be,  particularly  about  the  central  ganglia, 
foci  of  softening.  The  condition  is,  properly  speaking,  a  meningo-encephalitis. 
Probably  in  a  majority  of  cases  the  meninges  of  the  cervical  cord  are  involved. 
Sometimes  the  brunt  of  the  affection  falls  upon  the  spinal  meninges,  and  the 
exudation,  quite  insignificant  at  the  base  of  the  brain,  may  be  extensive 
throughout  the  cord. 

There  are  cases  in  which  the  coarse  tubercles  are  met  with,  and  the  menin- 
gitis has  been  excited  by  their  presence.  As  mentioned,  tubercles  usually 
exist  in  other  organs,  either  a  miliary  tuberculosis,  in  winch  the  liver  and 
spleen  are  most  involved,  or  careful  examination  will  show  the  presence  of 
caseous  foci  in  the  lymph-glands. 

Symptoms. — In  very  many  cases  the  patient  has  been  in  failing  health,  or 
is  the  subject  of  a  recognized  tuberculous  lesion,  or  has  had  a  recent  operation 
upon  some  tuberculous  affection,  or  is  convalescent  from  m(>asles  or  who()j)ing 
cough.  In  some  cases  the  symptoms  have  followed  shortly  after  a  fidl.  The 
child  may  show  marked  alteration  in  the  disj)ositioii  and  becomes  peevish,  irri- 
table, and  fretful,  sleeps  badly,  comj)lains  of  headache,  and  foi-  two  or  three 
weeks  may  display  various  manifestations  of  ill  lieahh.  Then  the  symptoms 
pointing  to  the  disease    set  in,  either    siiddeidy   with   a  eonvulsion    or  more 


G72  ORGANIC  DISEASES   OF   THE  BRAIN. 

commonly  with  headache,  fever,  and  vomiting.  The  pain  is  sometimes  very 
intense,  and  may  cause  tlie  child  to  give  short,  sharp  cries,  the  so-called 
"  hydrocephalic  cry."  Nocturnal  delirium  is  present.  The  vomiting  is  with- 
out apparent  cause  and  independent  of  the  taking  of  food.  The  fever  grad- 
ually rises,  reaching  102°  or  103°  F.  The  pulse  is  at  first  rapid;  subse- 
quently it  becomes  slow.  There  may  be  twitching  of  the  muscles  or  sudden 
startings,  and  the  child  may  wake  up  from  sleep  in  great  terror.  The  pupils 
are  usually  contracted.  These  are  the  chief  symptoms  characterizing  the  early 
stage,  or,  as  it  is  sometimes  called,  the  stage  of  irritation.  In  the  second 
period  of  the  disease  these  irritative  symptoms  subside ;  the  bowels  become 
constipated ;  the  child  no  longer  complains  of  headache,  but  is  dull  and  list- 
less, with  more  or  less  delirium ;  the  vomiting  ceases ;  the  abdomen  becomes 
retracted  and  boat-shaped  (carinated) ;  the  pulse  becomes  slow  and  irregular ; 
sighing  respiration  is  common ;  and  the  pupils  vary  in  size,  being  often 
dilated  ;  there  may  be  strabismus,  and  in  some  instances  optic  neuritis.  Gen- 
eral convulsions  may  occur;  more  commonly  there  is  retraction  of  the  head 
and  tenderness  in  the  nape  of  the  neck  on  pressure.  A  blotchy  erythema 
about  the  chest  and  abdomen  may  occur.  The  temperature  ranges  from  100° 
to  102.5°  F.  When  the  finger-nail  is  drawn  across  the  skin  a  red  line  quickly 
appears,  the  so-called  tache  cerebrale,  which  has,  however,  no  diagnostic  sig- 
nificance. In  the  final  period,  or  stage  of  paralysis,  the  child  can  no  longer 
be  roused,  and  gradually  sinks  into  a  condition  of  coma.  Convulsions  not 
infrequently  occur,  or  there  are  spasmodic  contractions  of  the  muscles  of  the 
back  and  neck,  or  there  are  irregular  movements  in  the  limbs  on  one  side. 
The  pupils  again  become  dilated  ;  the  eyeballs  may  be  rolled,  so  that  the  cor- 
nese  are  only  covered  in  part  by  the  upper  eyelid.  Optic  neuritis  and  paral- 
ysis of  the  ocular  muscles  may  occur,  and  tubercles  may  in  some  instances  be 
seen  in  the  choroid.  The  pulse  becomes  rapid,  diarrhoea  may  develop,  and  the 
child  sinks  into  a  typhoid  state,  with  low  delirium,  dry  tongue,  and  involun- 
tary discharges  of  urine  and  faeces.  The  duration  varies  from  ten  days  to 
three  or  four  weeks.  There  are  cases  which  run  a  rapid  course,  setting  in  with 
great  violence  and  proving  fatal  within  a  week.  This  occurs  more  commonly 
in  adults,  and  the  convexity  of  the  brain  is  often  more  involved.  There  are 
other  instances  much  more  chronic,  in  which  the  meningitis  is  limited,  and  the 
symptoms  are  rather  those  of  cerebral  tumor,  sometimes  with  pronounced 
psychi(!al  disturbance. 

Certain  symptoms  require  a  more  special  description.  The  temperature  is 
usually  elevated,  but  there  are  instances  in  which  it  does  not  rise  above '100° 
throughout  the  entire  disease.  In  other  instances  the  daily  oscillations  are 
very  great.  Toward  the  close  the  temperature  usually  falls,  and  may  sink  as 
low  as  93°  or  94°.  An  ante-mortem  elevation  may  occur,  the  fever  rising  as 
high  as  110°.  The  pulse  is  often  rapid  at  the  onset,  then  becomes  irregular 
and  slow,  and  toward  the  close  again  becomes  rapid.  The  respirations  are 
often  irregular  and  sighing,  and  in  the  second  and  third  week  the  Cheyne- 
Stokes  type  may  be  very  marked.    The  ocular  symptoms  are  important.    Nar- 


SIMPLE   MEXIXGITIS.  073 

rowing  of  the  pupils  is  the  rule  in  the  early  stage.  Toward  the  ch«e  they  are 
dilated  and  irregular.  Conjugate  deviation  of  the  eyes  sometimes  occurs. 
Paralysis  of  the  third  nerve  is  common.  Optic  neuritis  is  rarely  intense,  and 
is  not  a  very  common  symptom.  Tubercles  in  the  choroid  are  rare,  and  are 
less  frequently  seen  during  life  than  in  the  post-mortem  room.  I^itten 
found  them  in  39  of  52  necropsies  in  tuberculous  meningitis.  Of  26  cases 
examined  clinically  by  Garlick  they  were  present  in  only  1,  and  Pleinzel 
examined  41  cases  with  negative  results.  Of  motor  symptoms  the  convul- 
sions have  already  been  mentioned.  Tremor  and  athetoid  movements  are 
occasionally  seen  ;  more  rarely  there  is  a  tonic  contraction  of  one  limb.  Hem- 
iplegia may  follow  involvement  of  the  cortical  branches  of  the  middle  cerebral 
artery  or  is  due  to  softening  of  the  internal  capsule.  Mono})legias  are  not 
uncommon,  particularly  of  the  face,  which  may  occur  with  aphasia.  Brachial 
monoplegia  may  exist  \\\i\\  it.  In  the  more  chronic  cases,  in  which  the 
symptoms  persist  for  months,  there  may  be  characteristic  Jacksonian  epilepsy. 
The  prognosis  is,  as  a  rule,  very  grave.  It  is  doubtful  whether  recovery 
ever  occurs. 

(2)  Simple  Meningitis. 

In  contrast  to  the  tuberculous  form  the  exudation  is  more  apt  to  be  u])ou 
the  cortex,  and  is  less  lymplioid  and  more  purulent  in  character.  A  primary 
meningitis  of  this  description  occurs  as  a  manifestation  of  the  poison  of  cerebro- 
spinal meningitis,  sporadic  cases  of  which  occur  from  time  to  time  in  certain 
localities  in  this  country,  and  present  great  difficulties  in  diagnosis.  The  dis- 
ease is  almost  always  secondary  and  is  met  with — 

(1)  In  the  acute  infectious  diseases,  such  as  small-jwx,  tyj)h(»id  fever,  rheu- 
matic fever,  scarlet  fever,  measles,  and  ])neuraonia.  In  erysipelas,  iuHamma- 
tion  of  the  meninges  may  arise  either  by  direct  extension,  which  is  rare,  or  by 
infection  throup-h  the  blood.  Pneumonia  is  the  only  acute  disease  which  is 
frequentlv  followed  by  meningitis.  In  100  autopsies  in  this  disease  at  the 
Montreal  General  Hospital  meningitis  was  present  in  8  cases,  and  I  saw  sev- 
eral charcteristic  examples  at  the  Philadelphia  Hosjjital.  Acute  meningitis  is 
not  uncommon  in  sei)tic  processes.  In  ulcerative  endocarditis  its  frequency 
may  be  gathered  from  my  statistics — 29  examples  in  209  cases.  It  is  very 
rare  in  typhoid  fever.  No  case  occurred  in  my  64  autopsies,  and  it  was  pres- 
ent in  only  1 1  of  the  2000  Munich  sections. 

(2)  Injury  and  disease  of  the  cranial  bones  are  very  common  causes,  par- 
ticularly caries  of  the  ])etrous  portion  of  the  temporal  bone.  Here  the  disease 
pa.s.ses  through  the  thin  wall  of  the  tympanum  or  extends  from  tiie  mastoid 
cells,  and  is,  in  a  majority  of  instances,  associated  with  throml)osis  of  the 
dural  sinuses,  a  condition  which  will  be  considered  later.  Extension  from  di.s- 
ca.se  of  the  nose  is  very  rare.  The  majority  of  instances  of  injury  exciting 
meningitis  cause  fracture,  though  the  possibility  of  its  following  trauma  alone 
without  an  open  wound  must  be  acknowledged. 

(3)  Certain  constitutional  condition.s,  such  as  gout  and  Jiright's  disease,  are 

Vol.  I.— 4.3 


674  ORGANIC  DISEASES    OF   THE   BRAIN. 

occasionally  complicated  with  raeningiti.s.  In  gout  it  is  extremely  rare.  In 
Bright's  disease  cases  occasionally  occur,  and  are  usually  mistaken  for  uraemic 
poisoning.  They  are  sometimes  associated  with  inflammation  of  the  pericardium 
and  of  the  pleura.     The  exudation  may  be  chiefly  basilar. 

(4)  Among  doubtful  causes  which  are  mentioned  are  sunstroke  and  exces- 
sive study.  Syphilis  rarely  induces  acute  meningitis.  Occasionally  the  dis- 
ease extends  from  abscess  of  the  brain. 

Morbid  Anatomy. — The  lesions  are  practically  identical  with  those 
described  in  cerebro-spinal  fever.  The  exudate  is  usually  purulent  and  as  a 
rule  cortical,  particularly  in  the  cases  following  the  specific  fevers.  In  the 
meningitis  of  Bright's  disease  and  of  cachectic  states  the  basilar  meninges  may 
be  chiefly  involved.  In  the  form  secondary  to  pneumonia  the  exudate  may 
'be  extremely  abundant,  completely  covering  the  convolutions.  In  the  simple 
forms  of  meningitis  the  ventricles  rarely  present  the  distension  and  softening 
of  the  walls  so  frequent  in  the  tubercidous  variety.  In  many  instances  the 
condition  is  a  meningo-encephalitis,  and  the  cortical  portions  of  the  brain  are 
infiltrated,  cedematous,  and  sometimes  present  small  abscesses.  The  spinal 
meninges  are  often  affected. 

Symptoms. — Many  of  the  cases  present  a  clinical  history  similar  to  that 
already  described  in  the  tuberculous  form.  The  secondary  affection  occurring 
in  the  specific  fevers  is  very  difficult  to  recognize,  as  almost  identical  symp- 
toms may  be  caused  by  the  poisons  of  the  fevers  without  the  existence  of 
positive  inflammation.  For  example,  in  cases  of  so-called  cerebral  pneumonia 
in  which,  from  the  outset,  brain  symptoms  are  marked  (the  preliminary  excite- 
ment, headache,  delirium,  and  then  gradual  depression,  sinking  into  stupor 
and  coma),  unless  the  basilar  meninges  are  involved,  causing  local  palsies  of 
the  nerves — which  is  not  usual — there  is  no  single  feature  which  may  not  be 
present  as  a  result  of  extreme  congestion.  So  also  in  typhoid  fever,  the  cere- 
bro-spinal manifestations  may  lead  to  a  positive  diagnosis  of  meningeal  inflam- 
mation, and  the  twitchings,  spasms,  retraction  of  the  neck,  and  the  gradually 
deepening  coma  very  frequently  lead  to  error  in  diagnosis.  It  was  from  a 
consideration  of  these  cases  that  Stokes  remarked,  *'  There  is  no  single  nervous 
symptom  which  may  not  and  does  not  occur  independently  of  any  appreciable 
lesion  of  the  brain,  nerves,  or  spinal  cord." 

The  onset  is  more  apt  to  be  sudden  than  in  the  tuberculous  form.  Occa- 
sionally the  disease  sets  in  with  a  chill.  Headacheof  a  severe,  continuous  cha- 
racter is  the  most  common  symptom.  In  the  fevers,  however,  the  patient  may 
make  no  complaint.  Delirium  is  early,  and  often  bears  some  ratio  to  the 
height  of  the  fever.  Sometimes  the  patient  is  maniacal.  Convulsions  are 
much  less  common  in  simple  than  in  tuberculous  meningitis.  Rigidity,  spasm, 
and  twitching  of  the  muscles  are  frequent  symptoms.  Stiffness  and  contrac- 
tion of  the  muscles  of  the  neck  are  common  when  the  inflammation  extends  to 
the  meninges  of  the  cervical  cord.  Vomiting  occurs  in  the  early  stages.  Con- 
stipation is  usually  present.  Important  symptoms  are  due  to  involvement  of 
the  cranial  nerves;  thus,  optic  neuritis  may  develop,  but  it  is  not  common  in 


LEPTOMENINGITIS   INFANTUM.  675 

the  meningitis  of  the  cortex.  IMucli  more  frequently  the  third  nerves  are 
involved,  causing  strabismus  and  ptosis.  The  facial  nerve  may  be  attacked, 
causing  paresis  of  the  face  on  one  side,  and  a  lesion  of  the  fifth  may  be  followed 
by  disturbances  of  sensation  ;  and  in  one  of  my  cases,  in  which  the  Gasserian 
ganglion  was  infiltrated  with  pus,  the  cornea  ulcerated.  Tiie  pupils  vary  : 
they  may  first  be  contracted  or  unequal ;  later  they  become  dilated  and  react 
very  slowly  to  light.  The  pulse  is  rapid,  sometimes  irregular,  and  in  cases  in 
which  there  is  much  exudation  and  compression  of  the  brain  it  may  be  slow. 
The  temperature  range  varies,  and  in  tiie  forms  following  pneumonia  may  be 
very  high.  In  other  instances,  as  in  the  form  secondary  to  otitis  media,  the 
variations  are  greater.  In  non-tuberculous  meningitis  in  children  and  in  the 
disease  occurring  in  cachectic  individuals  the  fever  may  be  very  slight. 

From  what  has  been  already  said  it  is  evident  that  the  diagnosis  of  puru- 
lent meningitis  is  extremely  uncertain.  It  may  be  stated,  indeed,  that  unless 
the  nerves  at  the  base  are  involved,  causing  paresis  of  the  ocular  or  other 
muscles,  and  optic  neuritis,  there  are  no  positive  criteria  by  which  the  disease 
can  be  distinguished  from  the  so-called  cerebral  form  of  the  specific  fevers. 
It  has  been  a  common  experience  of  every  pathologist  to  have  cases  sent  down 
from  the  w'ards  with  the  explicit  diagnosis  of  meningitis,  cerebral  or  cerebro- 
spinal, when  the  section  showed  typhoid  lesions  or  a  local  patch  of  pneumonia. 
In  typhoid  fever  w^e  may  be  in  doubt  for  days  until  the  abdominal  symptoms 
become  plainly  manifest.  The  cases  secondary  to  bone  disease,  to  otitis  media, 
and  those  occurring  in  pysemic  processes  are  less  likely  to  escape  recognition. 

(3)  Leptomeningitis  Infantum. 

While  a  majority  of  the  cases  of  meningitis  in  children  are  tuberculous, 
there  is  a  form  affecting  infants  under  two  years  of  age  which  has  very  striking 
anatomical  and  clinical  peculiarities.  The  disease  may  ajipcar  shortly  after 
birth,  and  is  particularly  prone  to  affect  debilitated,  cachectic  children.  Occa- 
sionally it  follows  traumatism,  and  sometimes  is  associated  with  the  specific 
fevers.  Anatomically,  the  inflammation  is  confined  chiefly  to  the  base  and  to 
the  posterior  part,  particularly  about  the  cerebellum  ;  hence  it  has  been  termed 
posterior  meningitis,  or,  from  the  fact  that  the  foramen  of  Magendie  is  closed, 
leading  to  an  acute,  often  purulent  hydrocephalus,  the  condition  has  been 
termed  occlusive  meningitis.  The  exudation  may  be  very  abundant  at  the  base, 
infiltrating  the  membranes  and  covering  the  nerves  with  a  thick,  purulent 
exiidate.  In  many  instances  the  most  striking  features  arc  in  the  ventricles. 
The  posterior  and  descending  cornua  of  the  lateral  ventricles  may  be  enor- 
mously distended  with  a  greenish,  ])uridcnt  fluid,  and  the  ependyma  thickened 
and  infiltrated.  The  choroid  plexuses  and  the  velum  may  be  covered  with  a 
thick  grayish-white  exudate,  and  the  ependyma  of  the  third  ventricle  may  be 
similarly  involved.  In  some  cases  the  aqueduct  of  Sylvius  and  (he  finirth 
ventricle  are  greatly  enlarged,  and  the  ependyma  thickened  and  infiltrated  with 
a  grayish  pus.     In  one  instance  which  I  saw  the  basilar  meninges  were  but 


676  ORGANIC  DISEASES   OF   THE  BBAIN. 

slightly  involved,  while  there  was  a  condition  of  purulent  ependyniitis  in  the 
posterior  part  of  the  lateral  ventricles  and  in  the  fourth  ventricle. 

Fever,  vomiting,  convulsions,  and  rigidity  are  present  in  this  as  in  other 
forms.  The  most  striking  feature  is  the  holding  back  of  the  head — cervical 
opisthotonos — which  may  be  the  only  important  manifestation.  Under  this 
title  the  affection  has  been  described  by  Gee  and  Barlow.'  The  child  may 
remain  for  weeks  in  a  condition  of  extreme  weakness,  with  slight  irregular 
fever,  without  convulsions  or  rigidity,  but  with  this  strong  tonic  contraction 
of  the  cervical  muscles.  In  cases  which  have  lasted  for  some  time  the  head 
has  enlarged,  and  a  few  have  recovered  or  have  terminated  in  chronic  hy- 
drocephalus. 

Treatment  of  Meningitis. — Absolute  quiet  should  be  enjoined.  An  ice- 
bag  may  be  applied  to  the  head,  and  if  the  subject  be  young  and  full-blooded, 
and  particularly  if  under  these  circumstances  there  be  maniacal  delirium,  local 
or  general  bloodletting  may  be  practised.  Saline  purges  may  be  employed  to 
relieve  the  blood-pressure.  Bromides,  chloral,  sulphonal,  or  morphine  may 
be  required  to  procure  sleep  and  rest.  There  are  no  remedies  which  influence 
in  any  way  the  course  of  an  acute  purulent  or  tuberculous  meningitis.  Mer- 
curials are  recommended  for  the  purpose,  and  iodoform  inunctions  hav^e  been 
used  on  the  scalp  in  tuberculous  cases,  but  they  are  of  very  doubtful  efficacy. 
If  counter-irritation  be  thought  necessary,  the  thermo-cautery  lightly  applied 
is  the  most  satisfactory  means  to  employ.  In  traumatic  cases  and  in  disease 
of  the  ear  the  surgeon  should  be  early  in  attendance,  and  if  symptoms  occur 
which  justify  interference  trephining  should  be  performed. 

Chronic  Leptomeningitis. 

This  usually  results  from  the  growth  of  tubercles  or  gummata  in  limited 
regions  of  the  meninges.     It  sometimes  follows  trauma. 

The  symptoms  are  very  variable,  depending  upon  the  situation  of  the 
disease,  and  in  some  cases  are  identical  with  those  of  tumor.  When  in  the 
motor  region  there  may  be  Jacksonian  epilepsy.  The  leptomeningitis  infan- 
tum may  really  be  a  chronic  meningitis.  Some  of  the  cases  reported  by  Gee 
and  Barlow  lasted  for  more  than  a  year. 


n.  AFFECTIONS  OF  THE  BLOOD-VESSELS. 

Hyperemia  (Cerebral  Congestion). 

About  no  question  in  cerebral  pathology  is  there  more  obscurity  than  in 
relation  to  hypersemia  and  anaemia,  particularly  their  symptomatology.  Any 
one  wlio  reads  the  report  of  the  discussion  which  took  place  recently  at  the 

'  St.  Bartholomew's  Hospital  Reports,  1878. 


CEREBRAL    ANuEMIA.  677 

New  York  Neurological  Society  upon  the  subject  of  congestion  of  the  bruin 
will  be  convinced  that  the  extraordinary  lack  of  unanimity  can  only  be  cor- 
related  with  a  corresponding  absence  of  all  positive  and  satisfactory  know- 
ledge of  these  conditions.  Unquestionably,  variations  occur  in  the  amount  of 
blood  in  the  cerebral  vessels,  but  how  far  such  changes  are  associated  with  a 
definite  group  of  symptoms  is  not  at  all  certain.  The  hypertemia  is  usually 
described  as  either  active  or  passive. 

Active  hyperemia  is  stated  to  follow  chilling  of  the  surfiice,  sudden  sup- 
pression of  some  customary  discharge,  excessive  brain-work,  and  sunstroke. 
Alcohol  and  amyl  nitrite  also  cause  acute  hypersemia  of  the  cerebral  vessels. 

Passive  hypersemia  follows  obstruction  in  the  cerebral  sinuses  and  veins, 
engorgement  in  the  lesser  circulation,  as  in  mitral  stenosis  and  emphysema, 
pressure  on  tiie  superior  vena  cava  by  tumors,  and  from  prolonged  straining 
efforts. 

The  anatomical  changes  in  congestion  of  the  brain  are  not  at  all  striking. 
The  organ  looks  full  and  the  dura  is  tightly  stretched.  The  sinuses  and  the 
cortical  veins  are  full,  and  often  the  gray  matter  has  a  rosy  tint,  and  on  sec- 
tion it  is  seen  that  the  smaller  vessels  are  distended.  Active  hyperaemia  does 
not  persist  after  death,  as  is  well  seen  in  the  disappearance  of  the  areola  of 
congestion  about  a  pustule  on  the  skin.  The  most  intense  engorgement  of  the 
vessels  is  met  with  in  death  during  the  early  stages  of  the  specific  fevers  and 
in  the  cases  due  to  venous  obstruction. 

There  are  no  characteristic  or  constant  symptoms  of  cerebral  hypertemia. 
In  the  passive  form  it  may  exist  in  the  most  extreme  grade  and  without  the 
slightest  disturbance  of  function.  In  other  instances,  as  in  pressure  on  the 
superior  cava,  there  may  be  tor{)or,  but  rarely  couia.  The  headache  and  delir- 
ium of  the  early  stao-e  and  of  fevers  are  often  attributed  to  congestion  of  the 
brain,  but  it  is  more  likely  they  are  due  to  the  agents  which  excite  the  pyrexia. 
The  dizziness,  throbbing,  and  unpleasant  sensations  described  in  aortic  iusuf- 
ficiency  and  in  hypertrophy  of  the  heart  may  be  due  to  the  sudden  overfilling 
of  the  cerebral  vessels  during  systole. 

As  a  definite  (clinical  affection  congestion  of  the  brain  is  very  rare.  Per- 
sonally I  have  no  knowledge  of  the  cases  described  by  some  authors  setting  in 
with  fever,  delirium,  and  insomnia  ;  still  less  of  the  apoplectiform,  convulsive, 
and  comatose  forms.  Perhaps  the  most  definite  cases  are  those  met  with  in 
persons  of  a  full  habit,  who  are  subject  at  times  to  headache,  flushing  of  the 
face,  throbbing  of  the  carotids — symptoms  which  may  be  relieved  promptly 
by  an  attack  of  epistaxis  or  whicli  yield  to  a  brisk  mercurial  jmrge. 

Cerebral  Anemia. 

The  anjcmia  may  be  confined  to  locnl  areas  in  the  brain,  as  in  narrowing 
of  vessels  by  endarteritis  or  occlusion  l)y  emboli.  It  may  be  limited  to  the 
brain  itself,  as  in  cases  of  ligature  of  both  carotids,  or  in  dimitiished  blood- 
supj)Iy,  as  in  extreme  aortic  stenosis,  or  it  may  follow  the  sudden  dilatation  of 
a  vascular  territory,  as  in  rapid  distension  of  the  intestinal  vessels.     The  cere- 


678  ORGANIC  DISEASES   OF   THE  BRAIN. 

bral  anemia  may  be  part  of  a  general  bloodlessness  due  to  haemorrhage  or  is 
part  of  an  anaemia,  primary  or  secondary. 

The  brain  in  anaemia  is  pale ;  only  the  large  veins  are  full  ;  the  small  ves- 
sels over  the  dura  are  empty  and  the  membranes  are  moist ;  and  tliere  is  an 
unusual  amount  of  cerebro-spinal  fluid.  On  section  the  gray  and  white  mat- 
ter looks  very  pale,  and  the  cut  surfaces  moist  and  show  very  few  puncta 
vasculosa. 

The  consequence  of  cerebral  anaemia  when  suddenly  produced  is  well  seen 
in  a  fainting  fit,  in  which  loss  of  consciousness  follows  tlie  sudden  sinking 
of  the  arterial  pressure  in  the  cerebral  vessels.  When  it  results  from  haeraor- 
rhao-e  the  patient  complains  of  drowsiness,  giddiness,  a  feeling  of  faintness, 
flashes  of  light,  and  noises  in  the  ear ;  the  respiration  becomes  hurried ;  the 
skin  is  cool  and  covered  with  sweat ;  and  gradually,  if  the  haemorrhage  con- 
tinue, consciousness  is  lost  and  death  occurs  with  convulsions.  In  the  more 
chronic  forms  of  brain  anaemia  the  patient  may  be  subject  to  fainting  s[)ells, 
and  in  some  instances  headache  and  rambling  delirium.  In  the  anaemia  of 
wasting  disease  or  of  starvation  there  is  gradually  induced  a  condition  of 
irritable  weakness,  in  which  all  mental  effort  is  difficult  and  the  slightest  irri- 
tation is  followed  by  undue  excitement.  The  patient  complains  of  giddiness, 
noises  in  the  ear,  and  there  is  finally  developed  the  delirium  of  inanition, 
characterized  by  marked  hallucinations. 

An  interesting  group  of  symptoms  is  met  with  in  the  prolonged  malnu- 
trition of  young  children,  associated  usually  with  diarrhoea.  The  pupils  may 
be  narrow  or  unequal ;  the  head  is  thrown  back  and  the  child  is  in  a  semi- 
comatose state,  but  with  the  eyes  open  ;  convulsions  may  occur  and  the  fon- 
tanelles  ar^  usually  depressed.  The  body  is  usually  cool,  the  pulse  feeble  and 
raj)id,  and  the  respirations  normal.  It  was  to  this  condition  that  Marshall 
Hall  applied  the  term  "spurious  hydrocephalus,"  and  it  is  also  spoken  of  as 
the  hydrocephaloid  (hydrencephaloid)  condition.  The  cases  are  not  infre- 
quently mistaken   for  tuberculous  meningitis. 

The  treatment  of  cerebral  anaemia  is  that  of  the  conditions  with  which  it 
is  associated.  The  suddenly-developed  form  leads  to  syncope  or  fainting,  for 
which,  as  a  rule,  the  recumbent  posture,  the  dashing  of  cold  water  upon  the 
face,  superficial  friction,  and  the  inhalations  of  ammonia  suffice  to  restore  con- 
sciousness. If  the  syncope  persist,  a  tight  bandage  can  be  applied  round  the 
legs  or  the  abdominal  aorta  compressed  in  order  to  take  advantage  of  the  col- 
lateral fluxion. 

(Edema  of  the  Brain. 

This  is  often  only  a  complication  of  cerebral  anaemia.  An  increase  in  the 
subarachnoid  fluid  is  common  in  all  atr()])hic  states  of  the  brain.  In  extreme 
passive  hypersemia  there  may  be  a  congestive  oedema,  in  which  the  brain- 
substance  not  only  contains  an  increased  amount  of  blood,  but  is  unusually 
moist.  The  most  extreme  oedema  is  met  with  as  a  local  process  about  tumors 
and  abscesses.     A  very  intense  infiltration,  localized  or  general,  is  met  with 


CEREBRAL    HAEMORRHAGE.  679 

sometimes  in  chronic  Bright's  disease,  and  to  it  Traube  referred  certain 
urteraic  manifestations. 

When  a  sequence  of  atrophy,  the  fluid  is  chiefly  within  and  beneath  tiie 
membranes,  and  the  amount  of  fluid  in  the  ventricles  is  usually  increased. 
In  antemic  states  and  in  death  from  cachexia  the  brain-substance  is  pale,  moist, 
and  glistening. 

The  symptoms  are  not  well  defined,  and  are  chiefly  those  of  the  associated 
anaemia.  As  mentioned,  Traube  thought  that  ursemia  was  due  to  cerci)ral 
oetlema  consequent  upon  the  hypersemia  and  high  arterial  tension — a  view 
which  has  not  received  general  acceptance.  On  the  other  hand,  of  late  years 
cases  have  been  reported  of  localized  convulsions  and  of  paralysis  in  Bright's 
disease  in  which,  after  death,  no  lesions  other  than  oedema  have  been  found. 

Cerebral  Hemorrhage. 

Cerebral  hseraorrhage,  the  common  cause  of  apoplexy,  is  almost  invariably 
the  result  of  rupture  of  an  artery.  It  may  be  from  the  central  vessels  which 
pass  at  once  into  the  substance  of  the  brain,  from  the  large  branches  of  the 
circle  of  Willis,  or  from  the  cortical  group  which  is  distributed  upon  the  sur- 
face of  the  convolutions.  In  a  majority  of  the  cases  the  hjemorrhage  is  from 
the  central  branches,  particularly  from  those  which  pass  in  at  the  anterior  per- 
forated spaces.  The  largest  of  these  vessels  passing  to  the  third  division  of  the 
lenticular  nucleus  and  the  hinder  part  of  the  internal  capsule  is  so  frequently, 
involved  that  it  has  been  called  by  Charcot  the  artery  of  cerebral  hamorrliage. 
The  extravasation  may  be  into  the  substance  of  the  brain,  into  the  membranes, 
or  into  the  cerebral  ventricles. 

Etiology. — The  imjiortant  factors  are  those  leading  to  degeneration  of  the 
blood-vessels.  The  natural  tendency  to  arterial  degenerations  as  years  advance 
makes  hfemorrhage  much  more  common  after  the  fiftieth  year.  It  is,  how- 
ever, not  unknown  in  early  life,  and  in  ciiildren  may  be  due  to  rupture  of  an 
aneurism  or  to  local  degeneration.  It  occasionally  is  caused  by  the  paroxysms 
of  whooping  cough.  Cerebral  apoplexy  is  not  imknown  in  the  foetus.  As 
will  be  mentioned,  the  meningeal  hfemorrhage  is  a  very  frequent  and  imjK)rt- 
ant  event  in  protracted  labor,  but  hemorrhage  into  the  substance  of  the  brain 
may  itself  cause  death  in  the  foetus.  Men  are  more  fre(juently  attacked  than 
women — an  association  doubtless  due  to  the  greater  liability  in  the  former  to 
arterial  disease.  Heredity  is  believed  to  play  an  important  part,  and  the 
ai)0])lectic  build  or  habitus  is  still  spoken  of,  by  which  is  meant  a  stout, 
plethoric  frame  witli  a  short  neck  and  a  congested  condition  of  the  superficial 
vessels.  The  influence  appears  to  be  exerted  through  the  arteries,  as  (here  arc 
families  in  which  they  degenerate  early,  usually  in  association  with  renal 
changes.  The  three  special  factors  in  inducing  artcrio-sclerosis — namely,  the 
abuse  of  alcohol,  syphilis,  and  prolonged  muscular  cxcrlion — arc  important 
antecedents  in  a  largo  number  of  cases  of  cerebral  luemorrhage.  In  adult's 
hypertrophy  of  tlie  left  ventricle  and  sclerosis  of  (lie  kidneys  are  almost  con-, 
stant  concomitants  of  hemorrhage  into  the  brain.     The  endocarditis  following". 


680  ORGANIC  DISEASES    OF    THE  BRAIN. 

rlieumatism  and  i)ther  fevers  may  indirectly  lead  to  apoplexy.  The  cases  are 
not  verv  infrequent  in  young  persons.  Emboli  are  carried  oif  from  the  valves 
and  lead  to  softening  or  weakening  and  subsequent  aneurismal  dilatation  of  a 
cerebral  vessel,  and  haemorrhage  may  follow  rupture  of  the  aneurism. 

Haemorrhage  occurs  sometimes  during  the  course  of  the  specific  fevers; 
more  common  still  are  the  cases  due  to  profound  alteration  in  the  blood,  as  in 
anaemia  and  lenkgemia.  Occasionally,  too,  cerebral  haemorrhage  occurs  in  pur- 
})ura  haemorrhagica  and  in  scurvy. 

The  exciting  causes  are  not  often  evident.  The  attack  may  be  sudden,  with- 
out  any  preliminary  symptoms.  In  many  cases  the  rupture  occurs  during  vio- 
lent muscular  efforts,  such  as  straining  at  stool,  vomiting,  or  coughing,  or  in  very 
excited  action  of  the  heart  during  emotion. 

Morbid  Anatomy. — Lesions  are  found  in  the  cerebral  arteries  and  com- 
prise the  following  changes  : 

(1)  A  diffuse  periarteritis  of  slow  development,  which  causes  weakening 
of  the  coats  and  the  formation  of  small  miliary  aneurisms.  These  are  present 
in  the  great  majority  of  all  cases  of  haemorrhage  in  adults,  and  are  almost 
invariably  found  if  carefully  sought  for.  They  occur  most  frequently  on  the 
central  arteries,  but  also  on  the  smaller  branches  of  the  cortical  vessels.  They 
are  often  to  be  seen  on  section  of  the  brain-substance  as  small  dark  bodies 
from  1  to  3  millimetres  in  diameter.  They  may  be  present  in  numbers  upon 
the  arteries  withdrawn  from  the  anterior  perforated  space.  Charcot  and 
Bouchard,  who  first  accurately  described  them,  state  that  they  are  most  fre- 
quent in  the  central  ganglia. 

(2)  Larger  aneurisms  on  the  branches  of  the  circle  of  Willis,  which  are 
by  no  means  uncommon,  and  will  be  considered  in  a  separate  section. 

(3)  Endarteritis  and  periarteritis  usually  lead  to  haemorrhage  by  the  forma- 
tion of  aneurisms,  either  miliary  or  coarse.  There  are  cases,  however,  in  which 
careful  examination  fails  to  show  anything  but  a  diffuse  degeneration  of  the 
smaller  vessels,  and  doubtless  haemorrhage  may  occur  without  the  previous 
formation  of  aneurism. 

Finally,  there  are  instances  of  cerebral  haemorrhage  in  which  macroscop- 
ically  and  microscopically  the  changes  in  the  arteries  seem  insignificant. 

The  bleeding  may  be  into  the  meninges,  into  the  cerebral  substance,  or  into 
the  ventricles.  Meningeal  haemorrhage  may  be  outside  the  dura,  or  more  fre- 
quently subdural,  and  often  between  the  arachnoid  and  the  pia  mater.  In 
fracture  of  the  skull  causing  laceration  of  the  meningeal  vessels  the  blood  is 
usually  outside  the  dura  or  between  it  and  the  arachnoid.  In  rupture  of 
aneurisms  of  the  larger  cerebral  vessels  the  haemorrhage  is  usually  meningeal 
and  very  extensive,  and  may  extend  high  up  on  the  cortex  and  on  to  the  cord. 
Owing  to  the  more  frequent  presence  of  aneurism  in  the  middle  cerebral  ves- 
sels, the  Sylvian  fissures  are  often  found  distended  with  blood.  Intracerebral 
haemorrhage  may  burst  into  the  meninges.  The  meningeal  haemorrhage  of 
infants  resulting  from  injury  during  labor  will  be  subsequently  discussed 
under  the  section  upon  the  Cerebral  Palsies  of  Children.     More  or  less  ex- 


I 


CEREBRAL    H^EMOERHAGE.  681 

tensive  effusion  may  be  found  in  the  meninges  in  fevers,  and  oceasionally  in 
constitutional  diseases. 

Intracerebral  Hiemorrhage. — The  most  common  form  is  extravasation  in 
the  region  of  the  strio-lenticular  arter}',  about  the  outer  section  of  the  len- 
ticular nucleus.  If  small  in  extent,  it  may  be  limited  to  the  lenticular  body 
and  the  internal  capsule.  In  other  instances  it  extends  outward  to  the  insula 
or  upward  into  the  centrum  ovale  or  inward  to  the  lateral  ventricle.  Haemor- 
rhage into  the  centrum  ovale  is  not  nearly  so  common,  and  still  less  frequent 
are  localized  extravasations  into  the  pons,  medulla,  or  cerebellum.  The  haem- 
orrhage breaks  tiie  tissues,  and  the  clots  occupy  an  irregular  cavity  and  are 
mixed  with  brain-substance.  The  walls  are  at  first  irregular  and  composed 
of  blood-staint^d  and  softened  cerebral  matter. 

Ventricular  Hccmorrhage. — Primary  bleeding  into  the  ventricles  is  rare. 
The  blood  in  almost  all  instances  comes  from  rupture  of  an  extravasation 
into  the  ventricle.  It  is  not  very  infrequent  in  early  life,  and  may  occur 
during  birth.  Of  94  cases  collected  by  Edward  Sanders,  7  occurred  during 
the  first  year  and  14  under  the  twentieth  year.  It  occasionally  occurs  dur- 
ing parturition  and  in  the  puerperal  state.  There  is  in  the  jNIcGill  Uni- 
versitv  Museum  a  remarkable  instance  of  this  in  which  both  lateral  ven- 
tricles,  the  third,  the  aqueduct  of  Sylvius,  and  the  fourth  ventricle  are  enor- 
mously distended  with  clots  which  formed  a  complete  mould  in  blood  of  the 
ventricrlar  system.  The  blood  may  be  found  in  one  ventricle  only  ;  more 
commonly  it  reaches  the  other  ventricle,  either  bursting  through  »tiie  septum 
or  finding  its  way  through  the  foramen  of  Monro. 

In  all  instances  where  the  extravasation  is  at  all  large  the  liemisphore  on 
the  side  involved  looks  fuller  and  larger,  and  the  convolutions  are  fiattened, 
and  the  dura  on  the  affected  side  is  unusually  tense.  In  time  the  blood-clot 
undero-oes  chano-es.  The  hsemog-lobin  is  converted  into  reddish-brown  lucma- 
toidin  and  pigment-granules.  The  rapidity  with  which  these  changes  proceed 
varies:  as  a  ride,  in  cases  which  prove  fatal  within  a  month  brownish-yellow 
remnants  of  the  clot  are  found  with  disintegrated  brain-tissue,  molecular 
(lehria,  and  compound  granular  corpuscles.  A  limited  irritative  inflamma- 
tion occurs  about  the  clot,  and,  if  large,  a  definite  wall  is  formed,  enclosing  a 
cyst  with  fluid  contents.  In  smaller  clots  a  pigmented  scar  is  left.  In  men- 
ingeal hsemorrhage  the  effused  blood  may  be  gradually  absorbed,  leaving  only 
a  brownish  stain.  In  this  form  of  hsemorrhage  in  infants,  when  the  extrav- 
a.-ation  is  abundant,  wasting  of  certain  of  the  convolutions  may  take  place, 
and  sometimes  cvsts  form  in  the  meninges.  It  is  possible  that  certain  of  the 
cases  of  porencephaly  are  produced  in  this  way. 

>Secon(lan/  Defjeneration. — After  a  lesion  of  the  motor  centres  or  of  the 
j)yramidal  tract  secondary  degeneration  occurs  in  the  motor  |»ath.  Thus  in  a 
case  of  hemiplegia,  caused,  as  is  often  the  case,  by  a  ha'ini.rrhage  in  the  neigh- 
borhood of  the  internal  capsule,  a  descending  degencnitiou  is  seen  in  the  cms, 
in  the  anterior  part  of  the  pons,  in  tlie  pyramldiil  lil>i-es  of  the  medidla  on  the 
same  .side,  in  the  direct  fibres  of  the  cord  on  the  same  side  (coliunn  of  Turek), 


682  ORGANIC  DISEASES    OF    THE   BRAIN. 

and  in  the  crossed  pyramidal  fibres  of  the  opposite  side  of  the  cord.  In  per- 
manent cortical  lesions  the  secondary  degeneration  may  be  traced  through  the 
fibres  of  the  corona  radiata  and  into  the  internal  capsule,  and  through  the 
course  of  the  pyramidal  fibres  just  mentioned. 

Symptoms. — These  may  be  divided  into  the  primary,  or  those  connected 
with  the  onset  of  the  attack,  and  the  secondary,  or  late,  symptoms,  which 
develop  after  the  early  manifestations  have  passed  away. 

Premonitory  indications  are  not  common.  There  may  be  for  some  days 
or  even  for  weeks  headache,  feelings  of  numbness  and  tingling,  or  even 
pains  in  the  limbs.  Still  more  rarely  there  are  irregular  choreiform  move- 
ments of  the  muscles  on  one  side,  the  so-called  prehemiplegic  chorea.  As 
a  rule,  the  patient  is  seized  while  in  ordinary  health  about  the  performance 
of  some  every-day  action,  occasionally  such  as  requires  exertion  or  strain. 
When  the  haemorrhage  causes  sudden  and  complete  loss  of  consciousness, 
with  relaxation  of  the  limbs,  it  is  known  as  apoplexy  or  an  apoplectic 
stroke.  In  other  cases  the  onset  is  more  gradual,  and  the  loss  of  conscious- 
ness does  not  occur  for  a  few  minutes  after  the  patient  has  fallen  or  after  the 
paralysis  of  the  limbs  is  manifest.  In  an  apoplectic  attack  the  patient  is  seized 
with  giddiness  or  feelings  of  faintness,  sometimes  is  sick  at  the  stomach,  or 
has  a  slight  convulsion.  In  rare  instances  of  large  extravasations  the  patient 
dies  in  a  few  minutes,  but  instant  death  is  rare  in  cerebral  haemorrhage.  There 
is  deep  unconsciousness  from  which  the  patient  cannot  be  aroused.  The  face 
is  injected,  eometimes  cyanotic  or  of  an  ashen-gray  hue.  The  skin  is  usually 
moist  with  perspiration.  The  pupils  vary  in  size,  but  as  a  rule  are  dilated 
and  inactive.  They  may,  however,  be  strongly  contracted.  The  respirations 
are  slow,  noisy,  and  accompanied  with  stertor,  which,  as  Bowles,  has  shown, 
is  only  marked  when  the  patient  is  on  the  back,  and  is  owing  to  the  falling 
of  the  tongue  to  the  hinder  part  of  the  mouth. 

The  Cheyne-Stokes  rhythm  may  be  present.  The  pulse  is  usually  full, 
slow,  increased  in  tension,  and  sometimes  irregular  and  small.  The  tempera- 
ture may  be  normal,  but  very  often  falls  within  an  hour  after  the  onset,  and 
may  even  sink  below  95°  F.  An  exception  to  this  is  found  in  h:«morrliage 
into  the  pons  or  medulla,  in  which  within  an  hour  of  the  onset  the  tem- 
perature may  reach  104°  or  105°  F.  The  urine  and  faeces  are  usually  passed 
involuntarily.  Albumin  and  sugar  may  be  found  in  the  urine  very  shortly 
after  an  attack.  Convulsions  are  not  common  in  an  apoplectic  seizure  due  to 
haemorrhay;e. 

It  may  at  first  be  difficult  to  decide  whether  the  condition  is  apoplexy  asso- 
ciated with  hemiplegia,  or  whether  the  coma  is  due  to  other  causes,  such  as 
uraemia  or  opium-poisoning.  An  indication  of  the  hemiplegia  may  often  be 
discovered,  even  in  deep  coma,  by  a  difference  in  the  tonus  of  the  muscles  of 
the  two  sides.  If  tlie  arm  or  the  leg  be  lifted,  it  drops  "  dead  "  on  the  affected 
side,  while  on  the  other  it  falls  more  slowly.  One  side  may  present  marked 
rigidity,  and  in  watching  the  movements  of  the  facial  muscles  in  the  stertor- 
ous respiration,  if  paralysis  be  present,  it  will  be  noticed  that  the  cheek  on  the 


CEREBRAL    HEMORRHAGE.  683 

affected  side  is  puffed  and  blown  out  in  a  more  marked  manner.     The  head 
and  eyes  may  turn  strongly  to  one  side — conjugate  deviation. 

The  patient  may  at  first  not  lose  consciousness,  but  be  sligiitly  dazed,  and 
in  the  course  of  a  few  hours  there  is  loss  of  power  on  one  side,  and  gradual 
unconsciousness,  deepening  into  a  profound  coma.  This  is  sometimes  termed 
ingravescent  apoplexy.  The  attack  may  occur  during  sleep  and  the  patient  be 
found  unconscious,  or  he  may  wake  and  find  the  power  lost  on  one  side.  Cere- 
bral haemorrhage  is  not  necessarily  accompanied  by  the  symptoms  of  apoplexy  ; 
that  is,  with  loss  of  consciousness.  A  small  hoemorrhage,  particularly  in  the 
region  of  the  central  arteries,  may  involve  the  motor  path,  causing  hemiplegia 
without  any  loss  of  consciousness. 

The  subsequent  course  varies  greatly.  In  the  severer  cases  the  respirations 
become  more  rapid,  the  pulse  feeble,  the  skin  is  bathed  with  sweat,  the  color  of 
the  face  becomes  ashen-gray  or  livid,  noisy  rales  are  heard  in  the  trachea  and 
larger  bronchi,  and  death  may  occur  within  twenty-four  hours  of  the  onset. 
In  other  instances  the  patient  remains  unconscious,  and  within  forty-eight 
hours  there  is  some  febrile  reaction  and  constitutional  disturbance,  which  is 
associated  with  inflammatory  changes  about  the  haemorrhage.  The  patient 
may  die  in  this  reaction,  and  if  consciousness  has  been  regained  there  may  be 
delirium  or  recurren(!e  of  the  coma.  At  this  period  also  the  so-called  early 
rigidity  may  develop  in  the  paralyzed  limbs,  and,  more  important  still,  trophic 
disturbances,  such  as  sloughing  or  the  formation  of  vesicles.  The  most  serious 
trojihic  change  is  the  sloughing  eschar  which  develops  about  the  middle  of  the 
lumbar  region  on  the  })aralyzed  side,  and  is  different  from  the  eschar  of  acute 
myelitis,  which  develops  in  the  centre  of  the  sacral  region.  It  may  appear 
within  forty-eight  hours  of  the  onset,  and  is  of  very  grave  significance.  Some 
have  regarded  the  congestion  of  the  lungs  so  common  in  apoplexy,  and  which 
is  sometimes  unilateral,  as  an  evidence  of  a  trophic  change. 

Certain  symptoms  of  cerebral  haemorrhage  require  more  description  : 

Hemiplegia. — If  the  hemiplegia  involve  tiie  motor  centres  or  path,  loss  of 
power  occurs  in  the  muscles  of  the  opposite  side  of  the  body.  It  is  known  as 
complete  hemiplegia  when  it  involves  face,  arm,  and  leg;  partial  when  it 
involves  only  one  or  other  of  these  parts.  It  may  follow  a  lesion  in  the 
motor  cortex,  the  white  fibres  of  the  corona  radiata,  the  internal  cajjsule,  the 
cms,  or  the  pons.  Haemorrhage  is  perhaps  the  most  common  cause  of  hemi- 
plegia, but  it  is  alsi)  produced  by  embolic  and  thrombotic  softening  and  by 
tumors.  In  a  majority  of  severe  cases  of  haemorrhage  the  face,  arm,  and  leg 
are  involved  on  the  opjwsite  side.  In  other  instances  the  leg  and  arm  may  be 
chiefly  involved,  or  the  face  and  arm. 

Tlie  face  is  involved  on  the  same  side  as  the  arm  and  leg.  The  facial 
muscles  stand  in  precisely  tlie  same  relation  to  the  cortical  centres  as  do  those 
of  the  arm  and  leg.  The  fibres  of  the  upper  motor  segment  of  the  facial 
nerve  cominjr  from  the  cortex  decussate  just  as  do  those  of  the  nerves  of  (he 
limbs.     The  facial  paralysis,   however,  is  partial,   involving  oidy  the   lower 


684  ORGANIC  DISEASES    OF    THE   BRAIN. 

face,  sparing  the  orbicularis  oculi  and  the  frontalis  muscles.  There  may  be, 
however,  slight  difficulty  in  elevating  the  eyebrows  and  in  closing  the  eye  on 
the  paralyzed  side.  The  signs  of  the  facial  paralysis  are  usually  well  marked, 
and  the  mouth  is  drawn  toward  the  healthy  side.  The  tongue  may  be  pro- 
truded toward  the  paralyzed  side,  owing  to  the  unopposed  action  of  the  genio- 
hvodossus  of  the  sound  side.  It  is  to  be  remembered,  however,  that  the 
position  of  the  tongue  must  be  taken  from  the  incisor  teeth,  not  from  the  lips, 
which  are  drawn  toward  the  healthy  side,  so  that  the  tongue  even  when  pro- 
truded straight  may  appear  to  deviate  to  the  paralyzed  side.  With  hemi- 
plegia on  the  right  side  there  may  be  also  asphasia. 

As  a  rule  the  arm  is  more  completely  paralyzed  than  the  leg.  The  loss  of 
power  at  first  may  be  complete,  and  then  gradually  returns  in  the  leg,  still 
remaining  in  the  arm.  The  muscles  associated  in  symmetrical  movements, 
such  as  those  of  the  eyes  and  of  the  thorax  and  abdomen,  usually  escape.  It 
may  be  noted  in  the  deep  stertorous  respirations  that  the  chest  does  not  move 
so  freely  on  the  paralyzed  side.  Broad  bent's  explanation,  the  one  most  satis- 
factory, is  thus  clearly  given  by  Frederick  Taylor :  "  It  is  first  to  be  observed 
that  the  parts  that  are  least  paralyzed  or  not  paralyzed  at  all  are  those  which 
rarely  or  never  act  independently  of  their  fellows  on  the  opposite  side  ;  whereas 
the  parts  that  are  most  paralyzed  are  much  more  independent,  and  may  be 
capable  of  performing  acts  that  the  corresponding  muscles  on  the  opposite  side 
are  une(|ual  to.  As  extreme  instances  may  be  mentioned  the  eyes,  of  which 
one  never  moves  except  in  association  with  the  other,  their  muscles  not  being 
affected.  In  contrast  with  these  are  the  hands,  of  which  the  right  may  be 
able  to  do  things  the  other  cannot,  and  vice  verm;  and  these  parts  are  most 
affected.  Dr.  Broadbent's  theory  supposes  that  in  the  case  of  the  muscles  most 
commonly  associated  the  commissural  fibres  between  their  nerve-nuclei  become 
functionally  active,  so  that  in  the  event  of  a  lesion  preventing  one,  say  a  right- 
side  nucleus,  from  receiving  stimuli  from  the  left  brain,  it  may  be  stimulated 
from  the  right  brain  by  impulses  passing  first  to  the  left-side  nucleus,  and  then 
by  the  commissure  to  the  right-side  nucleus.  On  the  other  hand,  if  in  the 
case  of  the  less  associated  muscles  the  commissure  remains  functionally  inactive, 
such  a  transference  would  not  take  place,  and  the  right-side  nucleus  would 
remain  completely  cut  off  from  the  cortical  centres.  Another  view  has  been 
l)ut  forward  to  the  effect  that  fibres  for  the  face,  arm,  leg,  and  trunk  as  they 
pass  through  the  internal  capsule  have  positions  corresponding  to  those  of  the 
motor  centres  for  these  parts  on  the  cortex  ;  and  that  since  vessels  mostly  rup- 
ture below  the  internal  capsule,  and  the  pressure  would  most  injure  the  fibres 
which  were  nearest,  the  arm  Avould  suffer  more  than  the  leg,  and  the  leg  than 
the  trunk." 

The  face  and  limbs  may  be  paralyzed  on  opjwsite  sides,  forming  what  is 
known  as  the  crossed  or  alternate  hemiplegia.  This  occurs  when  the  hsemor- 
rhage  is  in  the  lower  segment  of  the  pons  Varolii,  involving  the  facial  nerve 
in  its  way  through  the  pons  after  it  has  left  its  nucleus ;  whereas  the  motor 
fibres  of  the  arm    and  leg  which  are  involved  in  the  lesion  arc  above  their 


CEREBRAL    HAEMORRHAGE.  685 

decussation  in  the  medulla,  so  that  the  paralysis  occurs  in  the  face  on  the  same 
side  as  the  lesion,  and  in  the  arm  and  leg  on  the  opposite  side. 

Hemiancesthesia  is  rare  in  hemiplegia.  Slight  numbness  or  tingling  may 
be  present,  or  there  is  loss  of  sensation  after  a  day  or  two,  which  gradually 
j)asses  off.  According  to  Dana's  study,  the  anaesthesia  of  organic  cortical 
lesions  was  generally  incomplete  and  more  pronounced  in  certain  parts  than 
in  others ;  total  anesthesia  was  either  functional  or  due  to  subcortical  lesions. 
Sensory  disturbances  are  more  common  in  softening  than  in  haemorrhage. 
Disturbance  of  the  special  senses  is  not  common.  There  may  be  diminution 
in  the  acnteness  of  hearing,  taste,  and  smell. 

The  eye-symptoms  in  hemiplegia  are  important.  Hemianopia  may  occur 
with  haemorrhage  in  the  occipital  lobe  or  in  the  fibres  of  the  optic  radiation. 
It  is,  however,  not  common  in  ordinary  hemiplegia.  The  most  important 
ocular  symptom   is — 

ConjiKjate  Deviation. — The  head  and  eyes,  as  a  rule,  are  turned  away  from 
the  affected  side;  thus  in  a  right  hemiplegia  the  eyes  and  head  are  turned  to 
the  left  side ;  that  is  to  say,  the  eyes  look  toward  the  cerebral  h^sion.  AVhen 
spasms  or  convulsions  develop,  or  if  the  state  of  early  rigidity  supervenes,  the 
liead  and  eyes  may  deviate  in  the  opposite  direction  ;  that  is  to  say,  the  patient 
looks  away  from  the  lesion  and  toward  the  convulsed  side.  This  symptom 
occurs  in  lesions  in  different  localities  of  the  brain,  particularly  with  cortical 
lesions.  It  is  also  met  with  in  lesions  of  the  internal  caj)sule,  and  in  those  of 
the  pons  or  in  the  latter  situations  it  has  been  found  that  the  deviation  is  just 
the  reverse  of  that  which  occurs  in  other  cases,  as  in  paralysis  the  patient  looks 
away  from  the  lesion  and  in  spasm  or  convulsion  looks  toward  it. 

As  a  rule,  there  is  no  wasting  of  the  paralyzed  limbs,  and  the  muscles  react 
well  to  both  the  faradic  and  the  galvanic  currents.  The  deep  reflexes  are 
increased  on  the  paralyzed  side ;  the  superficial  reflexes,  plantar  and  cremas- 
teric, are  often  diminished  or  absent.  The  sphincters  are  not  often  involved 
in  hemiplegia. 

The  course  of  the  disease  depends  upon  the  situation  and  extent  of  the 
lesion.  If  slight,  the  paralysis  may  disappear  completely  in  a  few  days  or  in 
a  few  weeks.  In  severer  cases  partial  recovery  gradually  takes  place,  asso- 
ciated with  which  are  the  changes  Avhich  may  be  grouped  as 

Secondarij  >Sympfom.s. — These  correspond  to  the  chronic  stage,  which  follows 
in  some  weeks  or  months  after  the  initial  lesion.  The  paralyzed  limbs  undergo 
certain  changes.  The  leg,  as  a  rule,  recovers  suflicient  i>()wer  to  enable  the 
patient  to  walk  about,  "init  with  a  characteristic  hemiplegic  gait.  The  loss  of 
jiower  is  most  marked  in  the  muscles  of  the  foot,  so  that  to  prevent  the  toes 
from  dragging  the  knee  is  much  flexed  and  the  foot  swung  round  in  a  half 
circle.  In  both  arm  and  leg  the  condition  known  as  secondary  contraction 
or  late  rigidity  supervenes;  the  arm  is  flexed  at  llic  elbow  and  resists  all 
attempts  at  extension;  the  wrist  is  flexed  ui)on  the  Ibrearm  .-iikI  the  fingers 
upon  the  hand.  The  position  assumed  by  the  arm  and  hand  is  very  character- 
istic.    Frequently  as  this  contraction  develops  there  is  nuicli   pain.      In  the 


686  OliGANIC  DISEASE^S    OF    THE  BRAIN. 

leff  the  contractures  are  not  so  extreme.  Unlike  the  contractures  of  hysteria, 
the  secondary  contracture  of  hemiplegia  is  not  relaxed  under  chloroform,  and 
is  an  incurable  condition,  associated  with  a  descending  degeneration  of  the 
motor  tract.  Occasionally  after  hemiplegia  secondary  contracture  does  not 
occur,  but  the  arm  remains  more  or  less  flaccid,  the  leg  having  regained  partial 
power.  This  condition  is  met  with  most  frequently  in  the  hemiplegia  of  chil- 
dren. The  reflexes  are  greatly  increased  on  the  paralyzed  side.  Atrophy  of 
the  muscles  is  not  a  marked  feature  in  hemiplegia,  but  develops  in  certain 
instances,  due  possibly  to  secondary  alterations  in  the  gray  matter  of  the  ante- 
rior horns.  It  may,  however,  follow  as  a  direct  result  of  the  cerebral  lesion, 
and  from  this  cause  is  not  very  infrequent  in  the  cerebral  palsies  of  children. 

Other  secondary  changes  in  hemiplegia  are  post-hemiplegic  disorders  of 
movement,  either  tremor,  choreiform  movements,  or  the  mobile  spasm  known 
as  athetosis.  These  will  be  more  fully  considered  in  the  hemiplegia  of  chil- 
dren, with  which  they  are  most  commonly  associated.  Arthropathies  may 
develop  early  in  hemiplegia,  but  more  commonly  develop  late,  and  are  most 
frequent  in  the  joints  of  the  arm.  They  take  the  form  usually  of  a  synovitis, 
with  swelling,  redness,  and  pain. 

Diagnosis. — This  may  be  extremely  difficult  if  the  patient  be  seen  for  the 
first  time  in  a  condition  of  deep  coma,  as  this  may  be  due  to  alcohol  or  opium 
or  to  ursemic  poisoning.  The  first  thing  to  be  determined,  if  possible,  is  the 
existence  of  hemiplegia.  Even  in  very  deep  coma  the  limbs  on  the  paralyzed 
side  are,  as  a  rule,  very  flaccid,  and  drop  instantly  when  lifted,  whereas  on  the 
other  side  the  muscles  retain  some  tonus.  Conjugate  deviation  of  the  head 
and  eyes,  rigidity  on  one  side,  or  spasm  on  one  side  are  suggestive  of  a  hemi- 
plegic  lesion.  In  a  majority  of  these  cases  it  is  practically  impossible  to  say 
at  first  whether  the  lesion  be  due  to  haemorrhage,  to  embolism,  or  to  thrombo- 
sis. Stiff"  arteries,  an  hypertrophied  left  ventricle,  and  a  sudden  onset,  with 
complete  loss  of  consciousness,  are  decidedly  in  favor  of  haemorrhage  or  of 
embolism,  while  a  more  gradual  onset  in  a  man  with  degenerated  vessels  is 
more  commonly  due  to  thrombosis.  The  most  puzzling  cases  are  those  in 
which  large  haemorrhage  occurs  into  the  ventricles  or  into  the  pons,  producing 
sudden  loss  of  consciousness  and  com[)lete  relaxation.  The  previous  history 
and  the  mode  of  onset  may  give  valuable  information.  In  epilepsy  the  con- 
vulsions have  preceded  the  coma  and  there  have  been  previous  attacks.  In 
alcoholism  the  odor  of  the  breath,  the  history  of  drinking,  and  the  more 
gradual  onset  are  points  to  be  considered.  In  opium-poisoning  the  coma 
develops  slowly  and  the  pupils  are  strongly  contracted.  In  ventricular  haem- 
orrhage sudden  and  rapidly  deepening  coma  occurs.  There  may  be  no  hemi- 
plegia, but  the  muscles  on  both  sides  are  equally  relaxed,  sometimes  with  a 
l)reliminary  rigidity  or  with  convulsions.  These  symptoms  may  be  the  very 
ones  to  lead  astray,  as  in  a  case  occurring  in  a  puerperal  patient,  in  whom 
albumin  and  tube-casts  were  present,  the  condition  was  naturally  enough 
believed  to  be  uraemic.  In  haemorrhage  into  the  pons  convulsions  are  frequent, 
the  pupils  may  be  strongly  contracted,  and  conjugate  deviation  may  occur,  the 


CEREBRAL    HJEMOUHHAGE.  687 

eyes  looking  away  from  the  lesion,  and  the  pupils  may  be  strongly  contracted, 
so  that  opium-poisoning  may  be  suggested.  The  temperature  may  rise  rapidly 
— a  point  of  considerable  diagnostic  value. 

At  first  it  may  be  quite  imjwssible  to  give  a  definite  diagnosis.  In 
emergency  cases  special  care  should  be  taken  upon  the  following  points  : 
The  head  should  be  examined  for  injury;  the  urine  should  be  drawn  off  at 
once  and  tested  for  albumin  and  sugar ;  the  limbs  should  be  inmiediately 
examined  with  reference  to  their  degree  of  relaxation,  the  presence  or  absence 
of  rigidity,  and  the  condition  of  the  reflexes.  The  state  of  the  pupils  should 
be  noted  and  the  temperature  taken.  Serious  mistakes  are  often  made  in  the 
case  of  individuals  who,  as  not  infrequently  happens,  are  drunk  at  the  time  of 
the  apoplectic  seizure.  The  condition  may  be  regarded  as  due  to  alcoholism  or 
to  uraemia.  In  pontine  hsemorrhage  respiration  is  often  disturbed,  and  may  be 
slow  as  in  opium-poisoning. 

Prognosis. — From  a  limited  cortical  haemorrhage  the  recovery  may  be 
complete,  particularly  if  the  haemorrhage  occurred  after  injury.  The  infantile 
meningeal  haemorrhage  causing  tiie  birth-palsies  is  very  frequently  followed 
by  idiocy  and  hemi-  or  dii)legia.  Large  extravasations  into  the  white  sub- 
stance of  the  hemispheres  and  into  the  ventricles  and  about  the  base  prove 
rapidly  fatal.  The  hemiplegia  following  a  lesion  of  the  internal  capsule  is 
usually  persistent  and  is  followed  by  contractures.  If  the  posterior  fibres 
have  been  involved,  there  may  be  hemianaesthesia,  and  later  hemichorea  or 
athetosis. 

The  following  symptoms  in  a  case  of  cerebral  haemorrhage  are  of  grave 
moment :  Persistence  or  deepening  of  the  coma  during  the  second  or  third 
dav,  rise  in  temperature  witiiin  the  first  twenty-four  hours  after  the  initial 
fall.  After  the  reaction  on  the  second  or  third  day,  with  which  there  is  usually 
moderate  fever,  a  gradual  fall  on  the  third  or  fourth  day,  with  a  return  of  con- 
sciousness, is  a  favorable  indication.  The  early  formation  of  a  sloughing  bed- 
sore is  very  unfavorable.  The  presence  in  the  urine  in  large  quantities  of 
albumin  and  sugar  is  an  unfavorable  symptom.  With  the  return  of  conscious- 
ness and  the  improvement  in  the  general  condition  the  question  is  anxiously 
asked  by  the  friends  as  to  the  persistence  of  the  paralysis.  In  adults,  if  the 
hemiplegia  has  been  complete,  involving  the  face,  arm,  and  leg,  and  if  it  per- 
sist for  a  week  or  ten  days,  there  is  little  hope  that  it  will  entirely  disappear. 
Slight  paralvsis  of  the  arm  and  face  without  profi)und  loss  of  consciousness 
may  be  recovered  from  com])letely,  but  complete  hemiplegia  which  persists  for 
a  month  usually  leaves  permanent  disability.  The  leg  imi)roves  as  a  rule,  and 
the  patient  is  able  to  walk  about  and  power  gradually  returns  in  the  fiice,  but 
the  hand  rarely  regains  control  of  the  finer  movements.  If  complete  motor 
aphasia  has  occurred,  the  chances  are  against  full  re-establishment  of  the  power 
of  speech.     The  late  rigidity  with  contractures  is  a  iioj)eless  condition. 


688  ORGANIC  DISEASES    OF   THE  BRAIN. 


Embolism  and  Thrombosis. 

(1)  Embolism. — The  most  common  cause  of  embolism  is  a  fresh  warty 
endocarditis  or  a  recurring  vegetative  inflammation  on  sclerosed  valves.  Some- 
times fragments  are  carried  off  from  segments  involved  in  an  ulcerative  process. 
The  miti-al  endocarditis  is  by  far  the  most  common  source;  less  frequently  por- 
tions of  clot  in  the  appendix  of  the  auricle  or  small  white  thrombi  are  respon- 
sible for  it.  Portions  of  thrombi  from  an  aneurism  or  from  atheromatous 
patches  on  the  aorta,  or  thrombi  from  the  territory  of  the  pulmonary  veins, 
may  also  block  the  branches  of  the  circle  of  Willis.  In  the  puerperal  con- 
dition cerebral  embolism  is  not  infrequent,  occurring  sometimes  in  women  with 
heart  disease,  but  in  many  cases  the  heart  is  uninvolved,  and  the  condition  is 
thought  to  be  associated  with  the  development  of  heart-clots  owing  to  an 
increased  coagulability  of  the  blood.  Practically,  a  large  proportion  of  all 
cases  of  embolism  occur  in  chronic  valvular  disease,  particularly  in  those  cases 
of  recurring  endocarditis  so  commonly  present  on  the  sclerotic  segments.  It 
is  much  less  common  in  the  acute  endocarditis  of  rheumatism,  chorea,  and  the 
acute  fevers.  The  emboli  pass  most  frequently  to  the  left  middle  cerebral 
arterv,  owing;  to  the  fact  that  the  left  carotid  is  more  in  the  direct  course  of 
the  blood-current  than  the  innominate.  The  posterior  cerebral  and  the  verte- 
bral arteries  are  less  often  involved.  A  large  embolus  may  lodge  at  the  bifur- 
cation of  the  basilar  artery.     Embolism  of  the  cerebellar  vessels  is  rare. 

The  statement  is  usually  made  that  embolism  of  the  cerebral  arteries  is 
more  fre(|uent  in  women,  owing  to  the  more  common  occurrence  of  mitral 
stenosis  in  them,  but  statistics  seem  to  indicate  that  cases  are  quite  as  frequent 
in  men,  if  not  more  common  ;  thus  Newton  Pitt's  recent  statistics  of  79  cases 
at  Guy's  Hospital  give  44  cases  in  males  and  35  in  females. 

(2)  Thrombosis. — Clotting  of  blood  during  life  in  the  cerebral  vessels  may 
be  due  to — 

(a)  The  presence  of  an  embolus.  About  a  fragment  of  clot  or  a  vegetation 
which  blocks  a  cerebral  artery  the  blood  coagulates  usually  as  far  back  as  the 
first  large  branch.  The  embolus  may  be  completely  surrounded  by  recent 
coagulum. 

(6)  Local  disease  of  the  cerebral  arteries,  either  a  simple  or  a  syphilitic 
endarteritis.  In  elderly  persons  with  advanced  atheromatous  changes  in  the 
larger  branches  of  the  circle  of  Willis  it  is  not  very  uncommon  to  find 
adherent  thrombi.  The  most  advanced  atheroma  may  exist  without  a  trace 
of  separation  of  the  fibrin,  and  in  all  probability  other  factors,  such  as  debility 
and  changes  in  the  constitution  of  the  blood,  are  necessary.  The  syphilitic 
endarteritis  is  a  nmch  more  common  cause  of  thrombosis.  The  growth  of 
tubercles  in  the  vessels  more  rarely  causes  thrombosis.  The  blood  may  clot  in 
aneurisms,  both  miliary  and  coarse.  Ligature  of  the  carotid  has  in  a  few 
instances  caused  the  formation  of  thrombi  in  the  arteries,  and,  as  a  rule,  of 
course  under  these  circumstances  the  collateral  circulation  is  readily  established. 
In  certain  blood-conditions  there  is  a  tendency  to  clotting  in  the  cerebral  vessels, 


EJIIiOLTSJr  AXD    rilROMBOSIS.  689 

a.s   in   marasmus   from   any  cause,   }>hthisis,  chlorosis,   and   in   the  puerperal 
state. 

Anatomical  Changes. — The  immediate  eticct  of  blocking  of  a  cerebral 
artery  is  degeneration  and  softening  of  the  vascular  territory  sup})lied  by  it. 
The  affected  district  is  rarely  in  a  condition  of  deep  hnemorrhagic  infarcti(jn,  as 
in  embolism  of  the  arteries  of  the  spleen  or  kidneys.  ^Nlore  commonly  the 
change  may  not  be  very  striking,  and  the  affected  area  nuiy  look  only  a  little 
paler  and  slightly  softer  than  nornud.  Gradually  the  consistence  of  the  j)arts 
lessens,  owing  to  the  infiltration  of  serum,  and  the  nerve-fibres  become 
degenerated  and  fatty,  and  the  neuroglia  swollen  and  cedematous.  The 
hanuoglobin  undergoes  a  gradual  transformation,  and  the  color,  which  is  red 
at  first,  changes  to  yellow.  Microscopically,  disintegrated  nerve-fibres,  fatty 
and  molecular  debris,  pigment-grains,  and  compound  granular  corpuscles  are 
present.  Much  stress  was  formerly  laid  uj)on  the  red,  yellow,  and  white  soft- 
ening, but  they  are  varieties  of  one  and  the  same  process.  The  red  .softening 
is  met  with  chiefly  in  the  gray  matter  of  the  cortex  and  of  the  ganglia.  It 
may  show  punctiform  haemorrhages  (capillary  apoplexy),  and  the  appearance 
may  be  almost  hsemorrhagic.  The  white  softenim/  is  most  common  in  the 
centrum  ovale,  and  its  most  typical  forms  occur  in  tiie  neighborhood  of  tumors 
and  abscesses  and  in  septic  processes.  YeUow  softening  is  usually  an  advanced 
stage  of  the  red.  There  is  a  variety  of  yellow  softening,  the  jjlaque  jaune, 
which  is  common  in  elderly  persons.  The  spots  are  from  1  to  2  cm.  in 
diameter,  with  cleanly-cut  edges,  and  the  softened  area  represented  either  by 
a  turbid  vellow  material,  or  in  the  advanced  stages  a  small  excavation  filled 
with  fluid  and  crossed  by  fine  trabecule.  A  dozen  or  more  of  these  patches 
mav  be  met  with  on  different  convolutions.  They  ]u-obal)ly  result  from  fatty 
or  hvaline  chauge  in  the  smaller  cortical  arteries. 

Inflammatory  changes  occur  about  the  softened  areas,  and  when  the  embolus 
is  derived  from  an  infected  focus,  as  in  ulcerative  endocarditis,  there  may  be 
suppuration.  The  final  changes  vary  greatly.  It  is  surprising  for  how  long 
a  period  red  and  yellow  softening  may  remain  unchanged.  Months  after  the 
attack  the  involved  area  may  be  oidy  slightly  depressed,  flattened,  somewhat 
softer  than  normal,  and  of  a  yellowish  color.  Finally  the  degenerated  and 
dead  tissue-elements  are  removed,  and  in  a  small  area  replaced  by  new  growth 
of  connective  tissue.  In  larger  regions  the  perii)heral  portion  of  the  softened 
area  becomes  condensed,  while  the  degenerated  elements  arc  absorbed  aud  a 
cyst  is  graduallv  formed,  sometimes  crossed  in  different  diicctious  by  connec- 
tive-tissue trabeculse. 

Softening  occurs  in  all  parts  of  the  brain,  more  ])articularly  on  the  cortex 
and  in  the  central  ganglia,  in  which  the  vessels  arc  terminal  arteries.  The 
extent  of  the  softening  de])cii(l>  ii|)()n  the  position  of  the  (Mubolus  and  tiic  j)os- 
sibilitv  of  establishinfr  a  collateral  circulation;  thus  an  end)()lus  blocking  the 
middle  <•(  lebral  at  its  origin  involves  both  the  central  arteries  passing  into  the 
anterior  perforated  space  and  the  cortical  branches.  Softening  in  th(>  corpus 
striatum  and  the  internal  capsule  in  such  a  case  is  inevitable,  and  as  a  rule  in 

Vol.  1.-44 


690  ORGANIC  DISEASES    OF    THE   BRAIN. 

part,  at  any  rate,  of  the  territory  supplied  by  the  middle  cerebral.  The  extent 
of  this  varies  very  much,  as  the  freedom  of  anastomosis  between  the  cortical 
branches  appears  to  differ.  There  are  instances  of  embolism  of  the  middle 
cerebral  artery  in  which  the  softening  has  only  involved  the  territory  of  the 
central  branches,  in  which  case  the  blood  must  have  reached  the  cortical  area 
through  the  anterior  and  posterior  cerebrals.  When,  as  is  perhaps  most  often 
the  case,  the  middle  cerebral  is  blocked  beyond  the  region  of  the  central 
arteries,  one  or  other  of  its  branches  is  most  involved.  The  embolus  may 
lodge  in  a  vessel  passing  to  the  third  frontal  convolution,  or  in  the  artery  of 
the  ascending  frontal  or  ascending  parietal  gyrus,  or  it  may  block  the  branch 
passing  to  the  supramarginal  and  angular  convolutions,  or  enter  the  lowest 
division  distributed  to  the  upper  convolutions  of  the  temporo-sphenoidal  lobe. 
These  are  practically  terminal  arteries,  and  when  involved  in  embolism  or 
thrombosis  softening  follows  in  part,  at  least,  of  the  territory  supplied  by  them, 
producing  in  this  way  some  of  the  most  accurately  focalizing  lesions  which  we 
meet. 

Symptoms. — The  most  extensive  softening  may  occur  without  causing 
any  symptoms,  as  when  the  occlusion  involves  arteries  passing  to  the  silent 
regions,  as  they  are  termed.  In  elderly  persons  it  is  quite  common  to  meet 
with  multiple  areas  of  the  plaques  jaunes  which  have  not  apparently  caused 
any  symptoms.  In  many  instances  the  symptoms  are  identical  with  those 
produced  in  hemorrhage,  and  transient  or  permanent  hemiplegia  is  produced 
with  or  without  loss  of  consciousness.  There  are  certain  peculiarities  asso- 
ciated with  the  attacks  of  embolism  and  thrombosis  respectively. 

In  embolism  premonitory  symptoms  are  rare ;  the  onset,  as  a  rule,  is  sud- 
den, without  any  headache,  numbness,  or  tingling.  The  patient  is  the  subject 
of  heart  disease,  or  there  exists  some  of  the  conditions  already  mentioned  as 
favoring  embolism.  When  the  embolus  blocks  the  left  middle  cerebral  artery, 
aphasia  is  usually  associated  with  the  hemiplegia. 

In  thrombosis  premonitory  symptoms  are  usually  present  and  the  onset  is 
more  gradual.  The  i)atient  has  complained  of  headache,  vertigo,  numbness  or 
tingling  in  the  fingers,  transient  weakness  on  one  side  or  in  the  arm  or  leg. 
The  speech  may  liave  been  embarrassed  for  some  days,  or  the  patient  has  loss 
of  memory  and  is  incoherent.  The  paralysis  may  begin  in  one  arm  and 
extend  slowly.  Abrujit  loss  of  consciousness  is  much  less  common  than  in 
embolism,  and  still  less  so  than  in  cerebral  haemorrhage;  thus,  with  thrombo- 
sis due  to  syphilitic  disease  the  hemiplegia  may  come  on  without  the  slightest 
disturbance  of  consciousness.  There  are  instances,  however,  of  extensive 
involvement  due  to  syphilis  in  which  the  patient  becomes  somnolent  and  is 
unconscious  for  days  or  even  weeks.  Convulsions  may  occur  with  embolism, 
rarely  with  thrombosis. 

The  general  symptoms  in  thrombosis  and  embolism  are,  as  a  rule,  not 
nearly  so  striking  as  in  cerebral  haemorrhage,  and  the  profound  apoplectic 
condition  with  stertorous  breathing  is  not  so  often  seen.  The  focal  symptoms 
are  practically  the  same,  and  the  hemiplegia  has  the  primary  and  secondary 


EMBOLISM  AND    THROMBOSIS.  691 

characteristics  described  under  Hferaorrhage.     The  following  are  the  eifects 
of  blocking  of  particular  vessels : 

(«)  Vertebral.  The  left  branch  is  usually  plugged,  and  results  in  an  acute 
bulbar  paralysis  from  involvement  of  the  nu<-lei  in  the  medulla.  It  may  be 
unilateral  and  associated  with  hemiplegia.  More  commonly  there  is  with  it 
(6)  Occlusion  of  the  basilar  artery,  which  may  cause  sudden  death  from 
involvement  of  the  respiratory  centres.  In  complete  occlusion  of  this  vessel 
there  may  be  bilateral  paralysis  from  involvement  of  both  motor  j)aths,  and 
bulbar  symptoms.  The  temperature  rises  rapidly,  and  there  may  be  hyper- 
pyrexia.    Death  occurs  as  a  rule  within  a  few  days. 

{(■)  The  posterior  cerebral  artery  supplies  the  occipital  lobe  on  its  inner 
face  and  the  greater  part  of  the  temporo-sphenoidal.  Localized  areas  of  soft- 
ening may  exist  without  symptoms.  Occlusion  of  the  branch  passing  to  the 
cuneus  may  be  followed  by  hemianopia,  and  hemianaesthesia  may  be  caused  by 
involvement  of  the  posterior  part  of  the  internal  capsule. 

((•/)  Internal  carotid.  The  symptoms  are  very  variable.  In  a  majority  of 
the  cases  the  vessel  may  be  ligated  without  any  risk.  Sometimes  transient 
hemiplegia  follows.  In  rare  cases  the  condition  is  persistent  and  death  has 
occurred.  These  variations  depend  upon  the  anastomoses  in  the  circle  of 
Willis,  which  if  large  and  free  readily  permit  of  the  collateral  circulation,  but 
when  the  anterior  and  posterior  communicating  vessels  are  very  small  or  are 
absent,  the  paralysis  may  persist.  When  the  internal  carotid  is  blocked  within 
the  skull,  and  particularly  by  the  formation  of  a  thrombus,  the  results  are 
much  more  serious,  as  the  process  is  apt  to  spread  into  the  branches.  Hemi- 
plegia, coma,  and  early  death  usually  follow. 

(e)  Middle  cerebral.  This  is  the  artery  most  commonly  involved,  and,  as 
already  mentioned,  when  plugged  before  the  central  arteries  are  given  off, 
permanent  hemiplegia  may  follow  from  softening  of  the  internal  capsule. 
Blocking  of  the  branches  beyond  this  point  may  be  followed  by  henn'plegia, 
which  is  more  likely  to  be  transient,  involving  chiefly  the  arm  and  face,  and, 
if  on  the  left  side,  associated  with  aphasia.  As  already  mentioned,  the  indi- 
vidual branches  passing  to  the  third  frontal,  the  ascending  parietal,  the  supra- 
marginal  and  angular  gyri,  and  to  the  temporal  gyri  may  be  })lugged. 

(/)  Tlie  anterior  cerebral.  Cortical  softening  in  the  district  supplied  by 
this  vessel  is  rare,  as  the  branches  from  the  middle  cerebral  are  usually  able  to 
effect  a  collateral  circulation.  Softening  of  the  orbital  lobule  and  the  olfactory 
bulb  may  occur.  Hebetude  and  dulness  of  intellect  may  exist  \w\i\\  obstruction 
of  this  vessel. 

Treatment  of  Cerebral  Hsemorrhage,  Enibolisni,  and  Thrombosis. — 
In  ccM'ebral  lueniorrhage  the  patient  should  be  placed  with  the  head  high,  and, 
if  stertor  ])(■  ])resent,  turned  on  the  paralyzed  side.  ]>owles,  who  has  written 
a  most  suggestive  work  on  the  subject,  calls  attention  to  the  great  ini]>ortance 
of  position  in  an  apoplectic  seizure,  holding  that  the  stertor  arises  largely  from 
the  tongue  falling  back  in  the  supine  jxisition  of  tlie  ixxly,  thus  offering  a 
serious  impediment  to  respiration.     In  the  lateral  position,  also,  the  mucus 


692  ORGANIC  DISEASES    OF   THE   BRAIN. 

and  sputa  drain  away  more  readtly.  In  a  majority  of  instances  the  pulse- 
tension  will  be  found  high,  and  measures  should  be  taken  to  reduce  it.  In 
part  this  increased  tension  may  be  due  to  the  suffocative  symptoms  associated 
with  the  stertor,  and  Bowles  states  that  the  pulse-tension  is  lowered  with  the 
relief  of  the  stertor  by  proper  posture.  The  most  rapid  and  satisfactory 
method  of  reducing  the  tension  when  very  high  is  venesection,  which  is  indi- 
cated in  the  case  of  middle-aged  men  with  arterio-sclerosis,  high  tension,  hyper- 
trophied  left  ventricle,  and  a  ringing  aortic  second  sound.  With  a  small  pulse 
of  low  tension  and  signs  of  cardiac  weakness  bleeding  is  contraindicated,  and  in 
the  cases  of  apoplexy  due  to  embolism  and  thrombosis  venesection  would  j)rob- 
ably  do  more  harm  than  good,  by  favoring  the  tendency  to  clotting.  Recently, 
on  experimental  grounds,  Horsley  and  Spencer  have  recommended  the  practice 
formerly  employed  empirically  of  compression  of  the  carotid,  particularly  in 
the  ingravescent  form  of  apoplexy.  In  suitable  cases  they  would  advise  even 
the  passing  of  a  ligature  around  the  vessel.  An  ice-bag  may  be  placed  upon 
the  head.  It  is  not  at  all  likely  that  sinapisms  to  the  feet  or  blisters  on  the 
back  of  the  neck  are  of  the  slightest  benefit.  The  bowels  should  be  freely 
opened,  either  by  calomel  or  by  croton  oil  placed  on  the  tongue.  Stimulants 
are  not  necessary  unless  the  pulse  becomes  feeble  with  signs  of  collapse,  when 
ammonia  and  brandy  may  be  administered.  Especial  care  should  be  taken  to 
avoid  bed-sores,  and  if  hot  bottles  are  used  to  the  feet,  it  should  be  remem- 
bered that  in  this  condition  burns  are  more  readily  caused  than  in  health. 
In  the  fever  of  reaction  aconite  may  be  cautiously  used. 

The  treatment  of  softening  from  thrombosis  or  embolism  is  unsatisfactory. 
Venesection,  as  it  lowers  the  tension  and  promotes  clotting,  should  not  be 
em])l()ycd.  If  the  pulse  be  feeble  and  irregular,  alcohol  and  small  doses  of 
digitalis,  with  ammonia  and  ether,  may  be  used.  The  bowels  should  be  kept 
open,  but  it  is  not  well  to  purge  actively  as  in  cerebral  haemorrhage.  In  the 
thrombosis  following  syphilitic  arteritis  we  see  very  satisfactory  results  from 
treatment.  In  such  cases,  met  with  most  frequently  in  men  between  the  ages 
of  twenty  and  forty,  the  hemiplegia  may  set  in  without  any  loss  of  conscious- 
ness. Iodide  of  potassium  should  be  given  freely  in  from  thirty-  to  sixty- 
grain  doses  three  times  a  day ;  and,  if  the  infection  be  recent,  mercury  may 
also  be  employed. 

Not  much  can  be  done  for  the  residual  hemi])legia  of  cerebral  haemorrhage 
or  embolism.  The  paralyzed  limbs  may  })e  rubbed  once  or  twice  a  day  to 
maintain  the  nutrition  of  the  muscles  and  to  prevent,  if  possible,  contractures. 
Electricity  is  probably  of  no  special  benefit,  and  it  is  certainly  not  comparable 
in  value  to  frictions  and  systematic  massage.  In  complete  hemiplegia  which 
persists  for  more  than  a  few  weeks  the  chances  of  full  recovery  are  slight. 
Power  returns  in  the  leg  sufficient,  as  a  rule,  to  enable  the  patient  to  get 
about.  The  movements  of  the  arm  at  the  shoulder-joint  are  regained,  but  the 
finer  movements  of  the  hand  are  permanently  lost.  In  permanent  hemiplegia 
in  persons  above  the  middle  period  of  life  mental  weakness  is  apt  to  super- 
vene, and  the  patients  often    become  emotional  and  irritable.      When  con- 


AXEUBISM   OF    THE    CEREBRAL    ARTERIES.  693 

tractures  develop  the  friends  should  be  .plainly  told  that  the  condition  is 
past  all  relief,  and  that  medicines  and  electricity  will  do  no  good,  and  that 
nothing  remains  but  to  look  after  the  general  health  and  comfort  of  the 
patient. 

Aneurism  of  the  Cerebral.  Arteries. 

Miliary  aneurisms  are  not  here  included,  but  only  the  coarse  aneurisms  of 
the  larger  branches. 

The  condition  is  by  no  means  uncommon.  I  have  reported  12  cases  met 
with  in  800  autopsies  at  the  Montreal  General  Hospital.  This  is  a  much 
larger  proportion  than  in  Newton  Pitt's  statistics  from  Guy's  Hospital,  in 
which  there  were  only  19  cases  in  9000  autopsies.  Males  arc  more  frequently 
atfected  than  females.  Of  my  12  cases,  7  were  in  males.  The  condition  may 
be  present  in  early  life.  One  of  my  cases  was  a  lad  of  six,  and  Pitt  describes 
one  at  the  same  age.  The  chief  causes  are  endarteritis,  simple  or  syphilitic, 
leading  to  weakness  of  the  wall  and  dilatation,  and  more  frequently  embolism. 
As  pointed  out  some  years  ago  by  Church,  the  aneurisms  are  usually  found 
associated  with  endocarditis.  In  his  recent  study  Pitt  concludes  that  it  is 
exceptional  to  find  cerebral  aneurism  unassociated  with  fungating  endarteritis. 
The  dilatation  follows  the  secondary  changes  in  the  coats  of  the  vessels  at  the 
site  of  the  embolus. 

The  middle  cerebral  arteries  are  most  frequently  involved.  The  distribu- 
tion in  my  12  cases  was  as  follows:  Internal  carotid,  1  ;  middle  cerebral,  5; 
basilar,  3;  anterior  communicating,  3.  Of  154  cases  which  make  up  the 
statistics  of  Lebert,  Durand,  and  Bartholow,  the  middle  cerebral  was  involved 
in  44,  the  basilar  in  41,  internal  carotid  in  23,  anterior  cerebral  in  14,  pos- 
terior communicating  in  8,  anterior  communicating  in  8,  vertebral  in  7,  pos- 
terior cerebral  in  6,  inferior  cerebellar  in  3  (Gowers).  The  size  varies  from 
that  of  a  pea  to  that  of  a  walnut.  The  aneurism  is  most  frequently  saccu- 
lated, and  communicates  with  the  lumen  of  the  vessel  by  an  orifice  smaller 
than  the  circumference  of  the  sac. 

A  cerebral  aneurism  may  attain  considerable  size  and  cause  no  symptoms. 
In  a  majority  of  the  cases  the  first  intimation  is  rupture  with  fatal  apoplexy. 
Symptoms  are  most  frequently  caused  by  aneurism  of  the  internal  carotid, 
which  may  com])ress  the  optic  nerve  or  the  chiasma,  causing  optic  neuritis. 
The  third  nerve  may  also  be  involved.  When  large  then^  may  be  irritative 
and  pressure  symjitoms  at  the  base.  In  a  case  reported  by  Weir  Mitchell  and 
Dercum  an  aneurism  compressed  the  chiasma  and  jiroduced  bilateral  tem])oral 
hemianopia.  Occasionally  a  murmur  may  be  audible  on  auscultation  of  the 
skull,  but  it  is  to  be  borne  in  mind  that  in  a  great  majority  of  instances  in 
which  a  murmur  can  be  heard  over  the  temporal  region,  even  at  a  distance 
from  the  skull,  it  indicates  simply  an  ordinary  systolic  brain-miu-inur  which  is 
of  no  special  significance.  Aneurism  of  the  vertebral  or  of  the  bnsilnr  artery 
may  involve  the  nerves  from  the  fifth  to  the  twelfth,  and  on  the  latter  artery 
it  may  compress  the  third  nerves  and  crura. 


694  ORGANIC  DISEASES   OF   THE  BRAIN. 

The  diagnosis  is,  as  a  rule,  inijiossible.  When  symptoms  exist  they  are 
those  of  tumor. 

Thrombosis  of  the  Cerebral  Sinuses. 

The  condition  may  be  primary  or  secondary,  and  the  clot  may  occur  in  the 
sinuses  alone  or  in  the  cortical  veins  as  well. 

Primary  Thrombosis,  which  is  rare,  occurs — 

(1)  In  children,  particularly  during  the  first  six  months  of  life,  following 
diarrhoea ;  in  older  children  after  any  exhausting  disease.  In  my  experience 
it  has  not  been  very  common  in  children,  and  the  only  records  among  my 
notes  relate  to  two  instances  of  meningitis,  both  with  thrombosis  in  the  corti- 
cal veins  as  well.  Gowers  believes  that  infantile  hemiplegia  is  not  infrequently 
caused  by  thrombosis  of  the  cortical  veins. 

(2)  In  connection  with  chlorosis  and  ansemia,  an  extremely  interesting  asso- 
ciation to  which  Brayton  Ball  has  called  si)ecial  attention,  having  collected  9 
cases  from  the  literature. 

(3)  In  the  terminal  stages  of  cancer,  phthisis,  and  other  diseases  causing 
cachexia.  In  hospital  and  general  practice  these  are  the  most  common  cases, 
and  the  clot  formed  under  these  circumstances  is  usually  spoken  of  as  "  maran- 
tic thrombus." 

Secondary  Thrombosis  is  very  much  more  common,  and  is  due  to  exten- 
sion of  inflammation  to  the  sinus-wall  in  disease  of  the  internal  ear,  in  frac- 
ture, in  suppurative  disease  outside  the  skull,  more  particularly  erysipelas. 
The  lateral  sinus  is  most  commonly  involved.  The  thrombus  may  be  small 
and  mural,  or  large,  filling  the  entire  sinus  and  extending  into  the  jugular 
vein.  Newton  Pitt  states  that  of  56  cases  in  which  aural  disease  caused  death 
with  cerebral  lesions,  in  22  thrombosis  existed  in  the  lateral  sinus.  In  more 
than  one-half  of  the  cases  the  thrombus  was  suppurating.  The  inflammation 
arises  usually  from  necrosis  of  the  posterior  wall  of  the  tympanum,  rarely 
from  disease  of  the  mastoid  cells.  The  most  extensive  sinus  thrombosis  may 
follow  erysipelas,  rarely  from  extension  directly  through  th*  bone  into  the 
longitudinal  sinus,  more  commonly  from  extension  along  the  nerves. 

Symptoms. — In  cases  of  prolonged  cachexia  in  which  death  has  taken 
place  slowly  a  thrombus  is  sometimes  accidentally  found.  In  other  instances 
there  is  mental  dulness,  headache,  and  gradual  torpor,  deepening  to  coma, 
without  any  localizing  symptoms.  In  involvement  of  the  longitudinal  sinus 
there  has  been  occasional  oedema  of  the  forehead,  and  distension  of  the  veins 
has  occasionally  been  noticed,  and  sometimes  epistaxis.  In  children  the  fon- 
tanelle  becomes  prominent,  and  there  may  be  exophthalmus.  Convulsions 
occur  in  some  cases,  and  there  may  be  vomiting.  In  the  chlorosis  cases  the 
head-sym])toms  have,  as  a  rule,  been  marked;  thus  the  patient  under  Ball's 
care  was  heavy  and  lethargic,  the  pupils  were  dilated,  and  there  was  double 
choked  disk.  There  was  also  slight  paresis  of  the  left  side.  In  the  cases  to 
which  he  refers,  reported  by  Andrew,  Church,  Tuckwell,  Owen,  and  Wilks, 
headache,  vomiting,  and  delirium  were  present.    In  Powell's  case,  with  similar 


THROMBOSIS    OF    THE    CEBEBRAL    SINUSES.  G95 

.symptom.";,  there  was  })aresis  oji  the  left  side.  Bri:?to\v's  ease,  an  aiuemie  g-irl 
aged  nineteen,  had  eonvulsions,  drowsiness,  and  vomiting ;  tenderness  and 
swelling  developed  in  the  position  of  the  right  internal  jugular  vein,  and  a 
few  days  later  on  the  opposite  side.  The  diagnosis  was  rendered  positive  by 
the  oecurrence  of  ])hlebitis  in  the  veins  of  the  right  leg;  swelling  also  occurred 
in  the  left  leg  in  Brayton  Ball's  case. 

The  diagnosis  of  primary  thrombosis  can  sometimes  be  made,  particularly 
in  chlorosis  eases,  in  which  the  thrombi  are  multiple.  In  infants  and  in 
the  forms  due  to  cachexia  the  symptoms  are  more  doubtfid.  In  thrombosis 
of  the  cavernous  sinuses  there  mav  be  oedema  of  the  eyelids  and  marked 
prominence  of  the  eyeballs.  I 

The  symptoms  of  secondary  thrombi  are  those  of  secondary  septicaemia. 
As  already  mentioned,  the  condition  most  frequently  follows  extension  from 
disease  of  the  middle  ear,  and  involves  the  lateral  sinus.  The  frequency  of 
this  accident  may  be  gathered  from  Pitt's  Guy's  Hospital  statistics,  already 
mentioned.  Headache,  chills,  and  fever  are  the  most  constant  symptoms. 
Earache  is  of  course  very  commonly  present,  and  of  other  symptoms  vomit- 
ing, coma,  delirium,  and  convulsions  occur.  Sometimes  there  is  great  j)ain  at 
the  back  of  the  head  and  the  neck  is  stiff.  When  the  thrombus  extends  into 
the  internal  jugular  vein,  there  may  be  local  fulness  in  the  lateral  region  of  the 
neck  or  abscess-formation  along  the  course  of  the  vein.  Optic  neuritis  may 
be  present.  The  duration  after  the  first  onset  of  the  symptoms  may  be  from 
ten  days  to  eight  or  ten  weeks.  As  a  rule,  the  patient  passes  into  a  typhoid 
condition,  with  dry  tongue,  rapid  })ulse,  and  all  the  symptoms  of  septicannia. 
In  three-fourths  of  the  cases  death  follows  from  pulmonary  pyaemia.  Pitt's 
deductions  from  his  cases  of  lateral  sinus  thrombosis  are  important :  1,  the 
disease  more  often  spreads  from  the  posterior  wall  of  the  middle  ear  than  from 
the  mastoid  cells ;  2,  the  otorrhoca  is  generally  of  some  standing,  but  not 
always  ;  3,  the  onset  is  sudden,  the  chief  symptoms  being  ])yrexia,  rigors,  pain 
in  the  occipital  region  and  in  the  neck,  associated  with  a  septicaemic  condition  ; 
4,  well-marked  optic  neuritis  may  be  present ;  5,  the  apjwarance  of  acute 
local  pulmonary  mischief  or  of  distant  suppuration  is  almost  conclusive  of 
thrombosis ;  6,  the  average  duration  is  about  three  weeks,  and  death  is  gen- 
erally from  ))ulmonary  ]>vaemia. 

Th(!  treatment  of  these  cases  is  most  unsatisfactory,  as  the  dangers  of 
])yaemia  are  extremely  great.  Pitt  recommends  that  the  internal  jugular  vein 
be  ligatured  in  the  neck,  the  lateral  sinus  opened,  and  the  clot  scra])ed  out. 
He  gives  an  interesting  case  of  a  boy  aged  ten  with  chronic  otorrhani  who  was 
admitted  with  earache,  tenderness,  and  oedema.  A  week  later  he  had  a  rigor, 
and  o])tic  neuritis  developed  on  the  right  side.  The  mastoid  was  incised  with- 
out results.  TIk'  rigors  and  pyrexia  continuing,  two  days  later  the  lateral  simis 
was  explored,  a  mass  of  foni  clot  removed,  and  the  jugular  vein  tied,  after 
which  the  boy  made  a  satisfactory  recovery. 


696 


OBGAXIC   DISEASES    OF    THE   BBAIN. 


Cerebral.   Localization. 

Onr  accurate  knowledge  of  the  functions  of  the  different  portions  of  the 
brain  dates  from  the  observations  of  Fritsch  and  Hitzig.  Previous  to  this 
time  interesting  attempts  at  localization  were  made  by  the  study  of  pathological 
cases,  and  to  Broca  and  Hughlings  Jackson,  more  than  to  any  others,  we  owe 
the  stimulus  to  the  clinical  study  of  this  question. 

In  the  cerebral  convolutions  there  are  areas  concerned  with  the  muscular 
movements — motor  centres  ;  with  sensation — sensory  centres  ;  with  the  special 
senses  of  sight,  hearing,  smell,  and  touch.  Tliere  are  also  psychical  centres 
about  the  situation  of  which  we  as  yet  know  very  little. 

Motor  Centres. — The  area  for  the  representation  of  movements  is  in  the 
Rolandic  region,  and  comprises  the  two  ascending  convolutions,  the  hinder  part 
of  the  three  frontal  convolutions,  and  a  part  of  the  parietal  lobule.  (See 
Fig.  45.)  Weak  electrical  currents  in  this  region  produce  muscular  move- 
ments in  the  opposite  side  of  the  body.  The  centres  presiding  over  the 
different  groups  of  muscles  are  thus  classified  : 

Fig.  45. 


Lateral  Surface  of  Brain  of  Monkey  (Horsley  and  Schafer). 

(a)  The  centres  for  the  trunk-muscles  are  situated  just  within  the  longitudi- 
nal fissure  in  the  marginal  gyrus,  in  the  region  sometimes  spoken  of  as  the 
paracentral  lobule  (Sehiifer).  (See  Fig.  46.) 

{b)  The  leg-centres  are  situated  at  tiie  upper  part  of  the  Rolandic  region. 
The  representation  of  movements  of  the  different  portions  of  the  leg  is  as 
follows  :  most  anteriorly,  the  hip ;  next  in  order,  the  knee  and  ankle ;  then 
the  big  toe,  the  centre  for  which  surrounds  the  upper  end  of  the  fissure  of 
Rolando  ;  and  still   farther  back  centres  for  the  small  toes. 

(c)  The  arm-centres  correspond  to  about  the  middle  two-fourths  of  the 
motor  area.  The  studies  of  Horsley  and  Beevor  have  shown  that  the  different 
segments  of  the  limb  are  represented  in  the  following  order  from  above  down- 
ward :  shoulder,  elbow,  wrist,  fingers,  the  index  finger,  and  last  of  all  the 
thumb. 


CEREBRAL    LOCALIZATION.  697 

{d)  The  centres  for  the  face,  tongue,  pharynx,  and  hirynx  are  situated  in 
the  hnvest  portion  of  the  Rolandic  region,  next  to  tiie  fissure  of  Sylvius.  From 
behind  forward  we  have  here  the  foUowing  centres :  (1)  opening  of  the  mouth, 

Fig.  A(S. 


Median  Surface  of  Brain  of  Monkey  (Horsley  and  Schafer). 


around  the  lower  end  of  the  fissure  of  Rolando  ;  (2)  movements  of  mastica- 
tion;  and  (3)  contraction  of  the  vocal  cords.  Anterior  to  this,  in  the  posterior 
part  of  the  third  left  frontal  convolution,  there  is  the  area  concerned  with  the 
motor  mechanism  of  speech.  In  front  of  the  j^rjccentral  sulcus  are  centres  for 
tiie  representation  of  movements  for  the  turning  of  the  head  and  eyes  to  the 
opposite  side. 

The  determination  of  these  various  motor  areas  has  been  worked  out 
accurately  in  animals,  and  has  been  established  in  the  case  of  man  partly 
by  careful  clinical  observation  and  partly  by  the  direct  ajiplication  of  elec- 
tricity to  different  regions  of  the  cortex  cerebri  during  operation.  The  various 
areas  for  the  representation  of  movements  in  the  cortex  must  not  be  regarded 
as  accurately  limited  and  defined,  but  as  blending  one  with  another. 

Uniting  these  cortical  motor  centres  and  the  gray  matter  of  the  spinal  cord 
are  the  fibres  of  the  pyramidal  or  motor  tract,  which  enter  the  white  matter  of 
the  hemispheres,  the  corona  radiata,  and  gradually  converge  to  what  is  known 
as  the  internal  cai>sule,  which  lies  between  the  thalamus  and  the  two  divisions 
of  the  corpus  striatum.  The  position  of  the  fibres  from  the  various  centres 
has  been  pretty  carefully  determined  and  represented  in  the  annexed  figure. 
(See  Fig.  47.)  The  fibres  from  the  centres  of  the  face,  tongue,  eyes,  and  head 
occupy  the  most  anterior  position,  just  at  the  knee,  as  it  is  called,  of  the  cap- 
sule; the  fibres  from  the  arm-centres  lie  close  to  these;  while  the  fibres  from 
the  leg-centres  occupy  a  position  in  the  middle  of  the  |»()sterior  j)art.  After 
leaving  the  internal  capsule  the  motor  fibres  ])ass  into  the  cms,  oecu|)ying  the 
lower  and  medial  position.  Passing  through  the  pons,  they  enter  tlir  medulla, 
of  whi(;h  they  fijrm  the  anterior  or  pyramidal  tract,  which  then  decussates,  a 
large  portion  of  the  fibres  passing  to  the  opposite  side  of  the  spinal  cord,  form- 


698 


ORGANIC  DISEASES    OF    THE   BBAIN. 


ing  the  crossed  pyramidal  tract,  a  smaller  number  of  the  fibres  descending  in 
the  anterior  column  of  the  same  side,  forming  the  direct  pyramidal  tract  or 
Turck's  column.  Ultimately  the  fibres  enter  the  gray  matter  of  the  spinal 
cord  and  join  the  plexus  of  the  protoplasmic  processes,  uniting  in  this  way 
with  the  large  nerve-cells  of  the  anterior  horns. 

Lesions  of  the  Motor   Centres  and  Cerebral  Motor  Path.— The  integrity  of 
the  fibres  of  the  motor  tract  depends  upon  the  vitality  of  the  cortical  ganglion- 


FiG.  47. 


Diagram  of  Horizontal  Section  through  the  Basal  Ganglia  and  Internal  Capsule  (left  side),  showing  the 
position  of  the  chief  tracts  in  the  internal  capsule.  The  region  of  the  capsule  marlced  by  the  letters 
L  A  F  is  occupied  by  motor  fibres ;  L  corresponds  to  the  leg-fibres,  A  to  the  arm-fibres,  F  to  the  face 
fibres  (including  fibres  to  face  muscles,  and  tongue).  The  region  F-C  contains  the  fronto-cerebellar 
tract  (intellectual  tract).  The  region  marked  S  contains  the  general  sensory  tract  from  the  opposite 
side  and  the  fibres  from  the  optic  and  olfactory  nerves  of  the  opposite  side,  sometimes  called  the"  sen- 
sory crossway"  (Herter). 


cells.  If  the  cells  from  which  they  arise  are  destroyed,  the  fibres  degenerate 
throughout  their  length  ;  that  is,  to  the  beginning  of  the  lower  or  spino-mus- 
cular  motor  path.  This  process,  known  as  secondary  or  Wallerian  degenera- 
tion, is  a  very  common  event  in  disease  of  the  brain  involving  the  centres  or 
the  pyramidal  tract. 

The  various  lesions  may  be  grouped,  as  Hughlings  Jackson  suggests,  into 
negative  or  positive,  or,  as  they  are  now  more  commonly  termed,  destructive 
and  irritative.  A  negative  or  destructive  lesion  anywhere  in  the  motor  path 
results  in  loss  of  function  in  the  parts — that  is,  paralysis ;  while  a  positive  or 
irritating  lesion  causes  perversion  of  the  function — i.  e.  abnormal  muscular 
eoutraction. 

(1)  Destructive  Lesions. — These  cause  paralysis,  with  secondary  de- 
generation and  certain  characters  which  distinguish  the  lesions  of  the  upper 
or  cerebro-spinal  tract.  Thus  the  paralysis  is  accompanied  by  a  condition  of 
spasm  shown  in  an  exaggeration  of  the  reflexes  and  an  increase  in  the  muscle- 
tension.  How  this  is  brought  about  is  not  yet  accurately  known,  but  the 
explanation  usually  offered  is  that  under  normal  circumstances  the  upper 
motor  centres  constantly  exert  a  restraining  influence  upon  the  lower  (spinal) 
centres.  When  this  influence  is  abolished  on  account  of  disease  in  the  pyra- 
midal tract,  these  lower  centres  take  on  increased  activity,  which  is  manifested 
by  an  exaggeration  of  the  reflexes.     As  the  segments  of  the  motor  path  are 


CEREBRAL    LOCALIZATION.  699 

separate  for  nutritional  purposes,  the  muscles  neither  undergo  degenerative 
atrophy  nor  present  the  reaction  of  degeneration. 

As  the  motor  centres  of  the  cortex  are  separated  more  or  less  from  each 
other,  a  localized  lesion  may  cause  limited  paralysis  contined  to  one  limb  or  to 
one  side  of  the  face — tiie  cerebral  monoplegias.  Where  the  pyramidal  fibres 
run  in  a  compact  bundle,  as  in  the  internal  capsule,  a  destructive  lesion  is 
more  apt  to  cause  paralysis  of  all  the  muscles  on  one  side  of  the  body  ;  that 
is,  hemiplegia. 

(2)  Irritative  Lesions.— Our  knowledge  of  such  lesions  is  confined  for 
the  most  part  to  those  acting  on  the  cortical  motor  centres,  and  we  know  a 
number  of  processes  which  have  as  their  result  abnormal  muscular  contrac- 
tions. These  have  as  their  type  the  localized  convulsive  seizures  classed  as 
Jacksonian  or  cortical  epilepsy,  which  are  characterized  by  the  convulsion 
beginning  in  a  single  muscle  or  group  of  muscles  and  involving  other  muscles 
in  a  definite  order,  depending  upon  the  position  of  their  representation  in  the 
cortex — for  instance,  such  a  convulsion  beginning  in  the  muscles  of  the  face 
next  involves  those  of  the  arm  and  hand,  and  then  the  leg.  The  convulsion 
is  usually  accompanied  by  sensory  phenomena  and  followed  by  a  weakness  of 
the  muscles  involved. 

A  majority  of  lesions  of  the  motor  cortex  are  both  destructive  and  irrita- 
tive— i.  e.  they  destroy  the  nerve-cells  of  a  certain  centre,  and  either  by  their 
growth  or  presence  throw  into  abnormal  activity  those  of  the  surrounding 
centres. 

Sensory  Centres. — Our  knowledge  of  the  exact  position  of  the  areas  for 
representation  of  the  sensory  impressions  is  still  defective.  Ferrier  places  it 
in  the  hippocampal  convolution,  but  the  experiments  of  Schiifer  suggest  that 
tiie  gyrus  fornicatus  is  also  concerned  in  sensory  impressions.  As  the  tactile 
and  muscular  senses  play  such  an  important  role  in  all  muscular  movements, 
and  are  sometimes  disturbed  in  lesions  of  the  motor  cortex,  it  seems  not  un- 
likely that  their  centres  are  associated  with  those  of  motion.  Horsley  has 
suggested  that  tliey  are  localized  in  the  motor  cortex,  and  that  two  of  the 
chief  layers  of  cells  in  this  region  may  possibly  subserve  their  functions. 
Dana's  study  of  a  large  collection  of  cases  indicates  that  anesthesia  is  very 
frequently  associated  with  lesions  of  the  motor  cortex,  more  particularly  in 
the  posterior  half  of  the  motor  area. 

Centres  for  the  Special  Senses. — As  already  mentioned,  the  cortical  itjm-c- 
sentation  of  the  sense  of  sight  is  in  the  occipital  lobe,  more  particularly  in  the 
cuneus,  unilateral  destruction  of  which  is  followed  by  hemian()i)ia.  The  rela- 
tion of  the  angular  gyrus,  which  Ferrier  believes  is  concerned  with  vision,  is 
still  undetermined,  and  it  seems  probable,  so  far  as  man  is  concerned,  that  the 
visual  area  is  in  the  occijiital  hjbe.  The  cortical  centre  for  hearing  has  not  yet 
been  fully  determined,  though  it  seems  to  bear  very  closf-  rrlatit)n  to  the  tcm- 
l)oral  lobe,  as  lesion  of  the  posterior  part  of  the  first  left  temporal  convoludon 
is  followed  by  llic  |)henomenon  known  as  word- deafness,  and  l)ilateral  destruc- 
tion  of  these  parts  in  the  monkey  jjroduces,  as  shown   by  l"\'rrier,  complete 


700  ORGANIC  DISEASES    OF    THE   BBAIN. 

deafness.  The  centre  for  smell  has  been  placed  by  Ferrier  in  the  teraporo- 
sphenoidal  lobe  and  in  the  uncinate  gyrus.  The  centre  for  taste  has  not  yet 
been  accurately  localized.  The  parts  of  the  brain  which  subserve  the  higher 
psychical  functions  are  believed  to  be  in  tlie  frontal  lobes.  This  opinion  is 
based  upon  the  greater  development  of  these  lobes  in  man  and  the  frequent 
association  of  mental  impairment  when  they  are  diseased. 

The  following  is  the  summary  of  the  functions  and  the  eifects  of  lesions  in 
other  reg-ions  of  the  brain  : 

Centrum  Ovale. — The  white  substance  situated  between  the  gray  cortex  and 
the  basal  ganglia  contains  (1)  the  projection  system  of  fibres,  which  unites  the 
cerebral  cortex  with  the  other  ganglionic  masses  and  with  the  spinal  cord  ;  (2) 
the  commissural  fibres,  which  join  corresponding  portions  of  the  hemispheres; 
and  (3)  the  association  tracts,  which  unite  adjacent  convolutions. 

Lesions  of  th.e  fibres  of  the  projection  system  cut  off  communication  with 
the  cortical  centres,  the  effect  of  which  naturally  depends  upon  the  portion  in- 
volved ;  thus  lesion  of  the  fibres  of  the  motor  path  causes  paralysis,  which  is 
practically  the  same  as  if  the  centre  itself  was  destroyed.  Subcortical  lesions 
involving  only  a  limited  number  of  the  projection  fibres  of  the  motor  path 
may  cause  monoplegias.  Lesions  in  the  white  matter,  as  the  fibres  converge 
to  the  internal  capsule,  are  more  likely  to  be  followed  by  hemiplegia.  Involve- 
ment of  the  white  fibres  of  the  optic  radiation  in  the  occipital  lobe  may  cause 
hemianopia  and  word-blindness,  and  of  the  fibres  of  the  temporal  lobe,  word- 
deafness.  Sensory  disturbances  are  rare  from  lesion  in  the  centrum  ovale 
proper,  but  hemiansesthesia  is  caused  by  destruction  of  the  fibres  near  the 
hinder  part  of  the  internal  capsule.  Interruption  of  the  association  tracts 
between  the  auditoiy  and  visual  centres  and  Broca's  convolution  may  cause 
forms  of  disturbance  of  speech,  and  a  lesion  interrupting  the  fibres  from 
Broca's  centre  causes  motor  aphasia. 

There  is  much  uncertainty  in  the  diagnosis  of  lesions  of  the  centrum  ovale, 
and  there  may  be  extensive  disease,  particularly  in  the  prefrontal  region,  with- 
out special  symptoms. 

Internal  Capsule. — As  already  stated,  this  important  tract  of  white  matter 
lying  between  the  thalamus  and  the  two  divisions  of  the  corpus  striatum  con- 
tains the  pyramidal  fibres,  the  sensory  fibres,  and  those  of  the  special  senses. 
The  diagram  already  given  shows  the  position  of  the  motor  fibres.  Briefly 
stated,  lesions  of  the  posterior  part  of  the  hinder  limb  of  the  internal  capsule 
cause  hemianesthesia  and  hemianopia,  and  there  have  been  instances  in  which 
the  special  senses  of  hearing,  taste,  and  smell  have  been  involved.  In  asso- 
ciation with  lesions  of  the  hinder  part  of  the  internal  capsule  and  the  con- 
tiguous portion  of  the  optic  thalamus,  choreiform  and  athetoid  movements  have 
been  described. 

So  far  as  we  know,  lesions  confined  to  the  caudate  and  lenticular  nuclei 
and  of  the  optic  thalamus  produce  no  definite  symptoms,  unless,  as  is  so  often 
the  case,  the  internal  capsule  be  simultaneously  involved. 

The   corpora   quadrigemina   are   rarely   diseased   alone.     Lesions   of  the 


APHASIA. 


701 


anterior  pair  result  in  blindness.  Pupillary  symptoms  are  common,  and 
there  is  usually  paralysis  of  the  oculo-motor  nerve.  Involvement  of  these 
parts  by  tumors  is  very  apt  to  be  followed   by  hydrocephalus. 

In  the  cms  cerebri  the  motor  and  sensory  fibres  are  collected  in  a  very 
small  space,  and  a  lesion  may  cause  hemiplegia  of  both  motion  and  sensation. 
The  third  nerve  is  frequently  involved  in  lesions  of  the  crus,  causing  paralysis 
of  the  muscles  of  the  eye  on  the  same  side  with  hemi))legia  on  the  opposite 
side.  Lesions  of  the  pons  in  the  lower  part  may  cause  paralysis  of  the  leg 
and  arm  on  the  opposite  side,  and,  involving  the  nucleus  or  fibres  of  the  facial 
nerve,  cause  paralysis  of  the  same  side  of  the  face.  This  is  known  as  crossed 
hemiplegia.  In  the  upper  part  of  the  pons  the  lesion  produces  the  ordinary 
type  of  hemiplegia.  Extensive  lesions  of  the  pons  involve  botii  pyramidal 
tracts,  causing  loss  of  power  in  both  sides  of  the  body. 

Aphasia. 

The  central  apparatus  concerned  with  speech  is  made  up  of  receptive,  per- 
ceptive, and  emissive  centres  in  the  cerebral  cortex,  the  disturbances  of  which 
are  considered  under  the  term  "aphasia."  Disturbance  of  the  centres  which 
preside  over  the  peripheral  speech-mechanism,  the  muscles  of  phonation  and 

Fig.  48. 


h  rn 


Lichtheim's  Schema. 


articulation,  produces  the  condition  known  as  anarthria,  as  in  the  gradual  loss 
of  the  power  of  speech  in  buli)ar  j)aralysis. 

Articulate  language  is  gradually  acquired  by  imitation  :  thus  in  teaching  a 
child  to  say  the  word  ''  bell  "  the  sound  of  the  word  as  uttered  enters  the 
afferent  path,  reaching  the  auditory  perce])tive  centre,  from  which  the  impidse 
is  .«ent  to  the  motor  or  emissive  centre  presiding  over  the  nuclei  in  the  nicdiilla, 
from  which  the  mu.sclcs  of  articulation  are  set  in  action.  'I'hc  aiv  in  Lulit- 
heim's  .schema  (.see  Fig.  48)  is  a\,  Mm.  In  this  way  the  child  gradually 
acquires  word-memories  which  are  stored  at  the  centre  A,  and  ni(»((.r  incin- 
orics — that  is  to  say,  the  memories  of  the  co-ordinating  muscular  movements 
necessary  to  utter  the  word — which  arc  .stored  at  the  letter  M.     So  also  when 


702  ORGANIC  DISEASES    OF    THE   BRAIN. 

shown  the  bell,  visual  memories  are  acquired  of  its  size  and  shape,  which  are 
conveyed  through  the  optic  nerve  to  the  visual  perceptive  centre  along  oO.  In 
the  auditory  perceptive  centres  is  also  stored  the  sound  of  the  bell  when  struck. 
The  memory  picture  of  the  shape  of  the  bell  or  its  sound  when  struck,  of  the 
appearance  of  the  word  when  written,  the  motor  memories  of  the  movement 
required  to  write  the  word,  are  distinct  from  each  other,  may  be  separately 
disturbed,  and  yet  are  intimately  connected  and  together  form  what  is  termed 
the  wo)'d- image.  In  addition  to  this,  the  child  gradually  acquires  ideas  as  to 
use  of  the  bell — intellectual  concepts,  the  centre  of  which  is  represented  at  I 
in  the  diagram.  In  volitional  speech,  as  in  uttering  the  word  "  bell,"  the  path 
Avould  be  represented  in  I,  M  m;  in  writing  the  path  would  be  represented  in 
I,  M,  W,  h.  The  various  "  memories  "  are,  as  a  rule,  centred  or  stored  in  the 
left  half  of  the  brain. 

Aphasia  in  the  widest  sense  of  the  word  may  be  taken  to  embrace  disturb- 
ances either  at  (a)  the  sensory  perceptive  centres  of  hearing  and  sight  and  in 
the  blind  of  touch  ;  (b)  of  the  emissive  or  motor  centres  of  speech  and  writ- 
ing; or  (c)  of  the  psychical  centres  through  which  we  gather  rational  concep- 
tions of  what  is  said  or  written,  and  by  which  we  express  voluntarily  our  ideas 
in  languao;e. 

Two  chief  forms  of  aphasia  are  recognized — the  sensory,  in  which  the 
psychical  and  sensory  ])erceptive  centres  are  disturbed ;  and  the  motor,  in 
which  the  emissive  for  speech  and  writing  are  involved. 

SeTisory  Aphasia. — Loss  of  the  jiower  to  recognize  the  nature  and  charac- 
teristics of  objects  is  known  as  apraxia,  which  is  thus  clearly  and  accurately 
defined  by  Starr:  "It  is  a  fundamental  position  involved  in  the  accepted 
theory  of  cerebral  localization  that  memories  are  the  residua  of  perceptions, 
and  are  therefore  localizable  in  the  regions  of  the  brain  concerned  in  percep- 
tion. It  follows  that  these  memories  forming  the  idea  of  an  object  or  an 
action,  being  distinct  from  one  another,  may  be  lost  by  disease  of  the  brain 
having  a  limited  extent,  and  that  the  character  of  the  memories  lost  will 
depend  on  the  location  of  the  disease.  Now,  cases  have  been  recorded  in 
which  persons  acted  as  if  they  no  longer  possessed  such  object  memories,  for 
they  failed  to  recognize  things  formerly  familiar.  A  fork,  a  cane,  a  pen  may 
he  taken  up  and  looked  at  by  such  a  person,  and  yet  held  or  used  in  a  manner 
which  clearly  shows  that  it  awakens  no  idea  of  its  use.  And  this  symptom, 
for  which  at  first  the  term  '  blindness  of  the  mind '  was  used,  is  found  to 
extend  to  other  senses  than  that  of  sight.  Thus  the  tick  of  a  watch,  the 
^ound  of  a  bell,  a  melody  of  music,  may  fail  to  arouse  the  idea  which  it  for- 
merly awakened,  and  the  patient  then  has  deafness  of  mind  ;  or  an  odor  or 
taste  no  longer  calls  up  the  notion  of  the  thing  smelt  or  tasted  ;  and  thus  it 
is  found  that  each  or  all  of  the  sensory  organs,  when  called  into  play,  may 
fail  to  arouse  an  intelligent  perception  of  the  object  exciting  them.  For  this 
general  symptom  of  inability  to  recognize  the  use  or  import  of  an  object  the 
term  apraxia  is  now  employed.  And  since  apraxia  is  a  symptom  which  is 
very  frequently  associated  with  aphasia,  and  which,  in  fact,   may  lie  at  the 


APHASIA.  703 

basis  of  apliasia,  it  should  always  be  looked  for  in  a  patient.  To  test  for 
jipraxia  it  is  only  necessary  to  present  various  objects  to  a  person  in  various 
-ways,  and  notice  whether  he  gives  evidence  of  recognition.  Have  him  watched 
by  his  friends,  and  they  will  be  able  to  tell  whether  he  still  chooses  his  articles 
of  food  at  the  table  intelligently — whether  he  still  knows  how  to  put  on  his 
<-lothes,  to  use  various  toilet  articles,  to  sew  or  knit  or  embroider  if  the  patient 
is  a  lady,  to  admire  pictures,  or  flowers,  or  perfumes,  as  before  the  illness 
began.  The  patient  may  or  may  not  be  able  to  name  these  objects :'  that,  at 
l)resent,  is  not  the  question.  But  is  it  evident  that  the  object  awakens  an  idea 
in  the  mind?"  There  are  instances  in  which  apraxia  may  be  the  only  symp- 
tom. Thus,  a  young  man  in  the  secondary  stage  of  sy[)hilis  was  r^eized  while 
at  his  office-work  with  a  convulsion.  A  day  or  two  subse(juently,  when  I  saw 
him,  there  was  no  paralysis  and  no  motor  aj)hasia,  but  he  had  completely  lost 
the  memory-pictures  of  faces  and  places.  The  street  in  wliieh  he  lived  was 
quite  unfamiliar  to  him,  and  he  did  not  know  his  way  to  the  office  at  which 
he  worked.  He  also  did  not  recognize  for  some  time  his  parents  or  brothers. 
As  a  rule,  apraxia  is  associated  with  varieties  of  sensory  and  motor  aphasia. 
The  patient  may  be  able  to  read,  but  the  words  arouse  no  intelligent  ideas  in 
his  mind.  While  blind  to  memory-pictures  aroused  by  sight,  tiic  j)crceptions 
may  be  stimulated  by  touch  ;  and  there  have  been  patients  imable  to  read  by 
.sight  who,  on  tracing-  the  letters  bv  touch,  named  them  correctly.  Mind- 
blindness  and  mind-deafness  are  the  common  and  imj)ortant  forms  of  a])raxia. 

Mind-blindness,  which  is  the  equivalent  of  visual  amnesia,  may  be  func- 
tional and  transitory  or  associated  with  organic  disease,  often  with  mental 
disturbance.  The  cases  collected  by  Starr  indicate  that  the  lesion  exists 
in  the  left  hemisphere  in  right-handed  persons,  and  in  the  right  hemi- 
sphere in  left-handed  persons.  The  disease  usually  involves  the  angular  and 
supramarginal  gyri  or  the  tracts  proceeding  from  them.  In  a  remarkable 
case  reported  by  ^lacewen  the  patient,  after  an  injury  to  the  head,  had  suf- 
fered with  headache  and  melancholia,  but  there  was  no  paralysis.  He  was 
psvchicallv  blind,  and,  though  he  could  see  everything  perfectly  well  and 
could  read  letters,  objects  conveyed  no  intelligent  impression.  A  man  before 
his  eyes  was  recognized  as  some  object,  but  not  as  a  man  until  the  sounds  of 
the  voice  led  to  the  recognition  through  the  auditory  centres.  Tiie  skull 
was  trephined  over  the  angular  gyrus,  and  the  iinier  table  was  found  to  be 
depressed  and  a  portion  had  been  driven  into  the  I)rain  in  this  region.  The 
patient  recovered. 

"Word-blindness  may  occur  alone  or  with  motor  aphasia.  TIk'  patient  is 
no  longer  able  to  recall  the  appearances  of  words,  and  does  not  recognize  them 
on  a  printed  or  written  page.  The  patient  may  be  able  to  pronounce  the  let- 
ters and  can  often  write  correctly,  but  he  cannot  read  understandingly  what  he 
has  written.  It  is  rare,  however,  for  the  patient  to  In-  able  to  write  with  any 
degree  of  facility.  There  are  instances  in  wliieli  llie  patient,  unable  to  read, 
lias  yet  been  able  to  do  mathematical  ])roblems  and  to  recognize  play-cards. 
The  lesion  in  cases  of  word-blindness  is,  in  a  majority  of  eases,  in  the  angular 


704  ORGANIC  DISEASES    OF    THE   BRAIN. 

and  supramarginal  g}^'!  on  the  left  side.  It  is  commonly  associated  with 
hemianopia,  and  not  infrequently  with  mind-blindness. 

Mind-deafness,  or  auditory  amnesia,  is  a  condition  in  which  sounds,  though 
heard  and  perceived  as  such,  awaken  no  intelligent  conceptions.  A  person 
who  knows  nothing  of  French  has  mind-deafness  so  far  as  the  French 
language  is  concerned,  and  though  he  recognizes  the  words  as  Avords  when 
sjxjken,  and  can  repeat  them,  they  awaken  no  auditory  memories.  The  musi- 
cal fjiculties  may  be  lost  in  aphasics,  who  may  become  note-deaf  and  unable  to 
appreciate  melodies  or  to  read  music.  This  may  occur'without  the  existence 
of  motor  aphasia ;  and,  on  the  other  hand,  there  are  cases  on  record  in  which 
with  motor  aphasia  for  ordinary  speech  the  patient  could  sing  and  follow  tunes 
correctly.  Word-deafness  is  a  condition  in  whicih  the  patient  no  longer  under- 
stands spoken  language.  The  memory  of  the  sound  of  the  word  is  lost,  and 
can  neither  be  recalled  nor  recognized  when  heard.  It  is  usually  associated 
M-ith  other  varieties  of  aphasia,  though  there  are  cases  in  which  the  patient 
has  been  able  to  read  and  write  and  speak.  The  lesion  in  word-deafness  has 
been  accurately  defined  in  a  number  of  cases  to  be  in  the  posterior  portion  of 
the  first  and  second  temporal  convolutions  on  the  left  side  (Plate  II.). 

Motor  or  ataxic  aphasia  is  a  condition  in  which  the  memory  of  the  efforts 
necessary  to  pronounce  words  is  lost,  owing  to  disturbance  in  the  emissive  cen- 
tres. This  is  the  variety  long  ago  recognized  by  Broca,  the  lesion  of  which 
was  localized  by  him  in  the  third  left  frontal  convolution.  In  pure  cases  the 
patient  is  able  to  read  (not  aloud),  and  understands  perfectly  what  is  said.  He 
may  not  be  able  to  utter  a  single  word  ;  more  commonly  he  can  say  one  or  two 
words,  such  as  "  no,"  "  yes,"  and  he  not  infrequently  is  able  to  repeat  words. 
When  shown  an  object,  though  not  able  to  name  it,  he  may  evidently  recog- 
nize M'hat  it  is.  If  told  the  name  he  may  be  able  to  repeat  it.  A  man  know- 
ing the  French  and  German  languages  may  lose  the  power  of  exj)ressing  his 
thoughts  in  them  while  retaining  his  mother-tongue,  or,  if  completely  aphasic, 
mav  recover  one  before  the  other.  As  the  third  left  frontal  convolution  is  in 
close  contact  with  the  centres  for  the  face  and  arm,  these  are  not  uncommonly 
involved,  with  the  production  of  a  partial  or,  in  some  instances,  a  complete, 
right-sided  hemiplegia.  Alexia,  or  inability  to  read,  occurs  with  motor  apha- 
sia and  also  with  word-blindness. 

As  a  rule,  in  motor  aphasia  there  is  also  inability  to  write — agraphia. 
When  there  is  right  brachial  monoplegia  it  is  difficult  to  test  the  capability, 
but  there  are  instances  of  motor  aphasia  without  paralysis  in  which  the  power 
of  voluntary  writing  is  lost.  The  condition  varies  very  much  ;  thus  a  patient 
may  not  be  able  to  write  voluntarily  or  from  dictation,  and  yet  may  copy  per- 
fectly. It  is  still  a  question  whether  there  is  a  special  writing  centre.  It  has 
been  placed  by  some  writers  at  the  base  of  the  second  frontal  convolution,  but 
in  a  recent  study  Dejerine  concludes  that  it  is  not  separated  from  the  speech- 
centre. 

There  is  a  form  known  as  mixed  aphasia  or  paraphasia,  in  which  the 
patient  understands  what  is  said,  and  speaks  even  long  sentences  correctly, 


APHASIA.  705 

but  constantly  tends  to  misplace  words,  and  does  not  express  his  ideas  in  the 
proper  words.  All  grades  of  this  may  be  met  with,  from  a  state  in  which 
only  a  word  or  two  is  misplaced  to  an  extreme  condition  in  which  the  patient 
may  talk  jargon.  In  these  cases  the  association-tract  is  interrupted  between 
the  auditory  perceptive  and  the  emissive  centres;  hence  it  is  sometimes  known 
as  Wernicke's  a{)hasia  of  conduction.  The  lesion  is  usually  in  the  insula  and 
in  the  convolutions  which  unite  the  frontal  and  temporal  lobes. 

Naunyn's  figure  (Plate  II.)  gives  an  accurate  representation  of  the  localiza- 
tion of  the  lesion  in  the  forms  of  motor  and  sensory  aphasia. 

Lichtheim's  schema  will  assist  the  student  in  obtaining  a  rational  idea  of 
the  varieties  of  aphasia  : 

1.  In  the  condition  of  apraxia  or  mind-blindness  the  ideation  centres,  I, 
are  involved,  often  with  the  auditorv  and  visual  perceptive  centres,  A 
and  O. 

2.  A  lesion  at  A,  the  centre  for  the  auditor\'  memories  of  words  (first  left 
temporal  gyrus),  is  associated  with  word -deafness. 

3.  A  lesion  at  O,  the  centre  for  visual  memories  (angular  and  supramargi- 
nal  gyri),  causes  word-blindness. 

4.  Interruption  of  the  tracts  uniting  A  M  and  O  M  causes  the  conduction 
aphasia  of  Wernicke — paraphasia. 

5.  Destruction  of  the  centre  M  (Broca's  convolution)  causes  pur(>  motor 
aphasia,  in   which  the  patient  cannot  express  thoughts  in  speeeii. 

A  lesion  at  M  usually  destroys  also  the  power  of  writing,  but,  as  stated,  it 
is  believed  bv  manv  that  the  centre  for  writino;:,  W,  is  distinct  from  that  of 
speech.  In  this  case  a  lesion  at  M,  which  would  destroy  the  ])ower  of 
voluntary  speech,  might  leave  open  the  connections  between  O  W  and  A  W, 
by  which  the  patient  could  copy  or  write  from  dictation. 

The  following  tests  should  be  applied  in  eacli  case  of  aphasia :  (1)  The 
power  of  recognizing  the  nature,  uses,  and  relations  of  objects — i,  e.  whether 
apraxia  be  present  or  not;  (2)  tlie  jiower  to  recall  the  names  of  familiar  objects 
seen,  smelled,  or  tasted,  or  of  a  sound  when  heard  or  of  an  object  touched  ; 
(3)  the  power  to  understand  spoken  words;  (4)  the  capability  of  understand- 
ing printed  or  written  language ;  (5)  the  power  of  appreciating  and  understand- 
ing musical  tunes ;  (6)  the  power  of  voluntary  speech — in  this  it  is  to  be  noted 
])articularly  whether  he  misplaces  words  or  not;  (7)  the  power  of  reading 
aloud  and  of  understanding  what  he  reads;  (8)  the  ])ower  to  write  voluntarily 
and  of  reading  what  he  has  written  ;  (9)  the  power  to  copy  ;  (10)  the  |H>wer 
to  write  at  dictation  ;  and   (11)  the  power  of  repeating  words. 

Treatment. — In  the  young  aphasia  associated  with  hemiplegia  lV(»ni  what- 
ever cause  is  usually  transitory,  and  they  quickly  learn  to  talk,  proi)al)ly  by 
education  of  the  centres  of  the  opposite  side  of  the  brain.  In  adults  the  con- 
tlition  is  nnich  less  hopeful,  parti(;ularly  in  cases  of  eomijlete  motor  aphasia 
with  right  hemiplegia.  Sometimes  the  recovery  is  raj)id  ;  in  others  partial 
rew)very  occurs  and  the  |)atient  is  able  to  talk,  l)ut  lie  misplaces  words.  If 
motor  aphasia  has  persisted  for  seveial  months  without   improveiinrit,  the  eon- 

VoL.  I.— 4a 


706  ORGANIC   DISEASES    OF    THE   BRAIN. 

dition  is  generally  hopeless  and  the  patient  may  remain  speechless,  thongh 
capable  of  understanding  .  everything  that  is  said.  The  education  of  an 
aphasic  demands  the  utmost  patience,  and  when  the  patients  are  emotional 
and  irritable  the  attempts  are  often  futile.  Detached  letters  should  be  at  first 
used,  with  which  small  words  of  one  syllable  may  be  constructed,  and  prog- 
ress made  slov^dy.  The  most  distressing  cases  are  those  of  permanent  aphasia 
with  rio-ht  hemiplegia.  When  the  mental  condition  is  good,  the  patient  may 
with  great  care  be  taught  to  write  with  the  left  hand,  and  so  have  a  medium 
of  communication.  Too  often  the  utmost  care  and  pains  prove  fruitless  in 
these  cases. 

Cerebral  Palsies  of  Children. 

In  children  palsies  due  to  cerebral  disease  occur  with  a  frequency  almost 
equal  to  those  of  spinal  origin. 

1.  Hemiplegia. — The  disease  appears  to  be  somewhat  more  frequent  in 
girls;  thus  in  my  series  of  135  cases,  comprising  cases  from  the  Infirmary  for 
Diseases  of  the  Nervous  System,  Philadelphia,  from  the  Elwyn  Institution  for 
Feeble-minded  Children,  and  from  my  clinic  at  the  Johns  Hopkins  Hospital, 
75  were  girls.  In  a  large  majority  of  cases  .the  disease  sets  in  during  the 
first  or  second  year  ;  thus  of  the  total  number  of  cases,  95  were  under  two 
years  of  age.  Above  the  fifth  year  the  disease  is  rare — there  were  only  10 
cases  in  my  series.  Neither  alcoholism  nor  syphilis  in  the  parents  plays  a 
role  in  the  affection.  Injury  with  the  forceps  in  instrumental  delivery  is  an 
occasional  cause,  though  not  so  important  as  in  the  spastic  diplegia  and  para- 
plegia of  children.  Falls  and  punctured  wounds  are  occasionally  causes,  and 
in  one  instance  in  the  Elwyn  Institution  the  hemiplegia  followed  ligation  of 
the  common  carotid.  A  certain  number  of  cases  set  in  during  the  height  of 
or  follow  an  infectious  fever.  In  my  series  cases  are  mentioned  after  scarlet 
fever,  measles,  whooping  cough,  and  vaccinia.  There  are  cases  in  the  litera- 
ture mentioned  also  after  mumps.  In  some  of  these  instances  the  paralysis 
followed  the  initial  convulsion  ;  in  others  it  was  not  until  the  fever  had  sub- 
sided that  fits  came  on,  and  with  them  paralysis.  In  the  whooping-cough 
cases  the  hemiplegia  may  follow  a  prolonged  spasm  of  coughing,  but  in  the 
three  cases  in   my  series  it  occurred  with  convulsions  during  the  disease. 

In  a  large  majority  of  the  cases  the  disease  sets  in  with  severe  convulsions, 
often  without  any  premonition,  and  in  children  who  have  previously  been 
robust  and  healthy.  The  imjiortance  of  convulsions  in  this  affection  may  be 
gathered  from  the  combined  statistics  (those  of  Wallenberg,  Gaudard,  Gowers, 
Sachs,  and  my  own),  numbering  428  cases,  of  which  nearly  one-half  set  in 
with  convulsions. 

Morbid  Anatomy. — The  nature  of  the  primary  lesion  is,  in  a  majority  of 
the  cases,  unknown.  The  autopsies  which  have  been  reported  have  almost 
invariably  been  late,  years  after  the  onset  of  the  hemiplegia.  In  an  analysis 
which  I  made  of  90  autopsies  from  the  literature  the  lesions  could  be  grouped 
as  follows : 


CEREBRAL    PALSIES    OF    ClflLDREX.  707 

(a)  In  16  eases  tliere  was  embolism,  tlirombosis,  or  hfeniorrliagc.  In  7 
of  these  a  Sylvian  artery  was  oeelnded ;  in  9  there  was  lueinorrha(2;e.  It  is 
interesting  to  note  that  in  10  of  these  cases  the  <lisease  set  in  in  children  over 
six  years  of  age. 

(6)  Atrophy  and  sclerosis,  which  are  the  common  conditions  in  the  majority 
of  the  cases.  The  wasting  is  either  of  gronps  of  convolutions,  an  entire  lobe, 
or  one  hemisphere.  The  meninges  may  look  normal,  though  more  commonly 
they  are  tightly  adherent  and  the  brain-substance  tears.  The  convolutions  are 
shrunken,  firm,  and  hard.  In  some  instances  there  is  a  remarkable  unilateral 
atrophy,  in  which  the  brain-tissue  is  a  mere  shell  over  the  greatly  dilated  ven- 
tricle. Thus,  in  one  of  my  cases  the  atrophied  hemisphere  weighed  169 
grammes  and  the  normal  553   grammes. 

(c)  Porencephalus,  which  was  present  in  24  of  the  90  autopsies.  This 
term  was  applied  by  Ileschl  to  a  loss  of  substance  in  the  form  of  cavities 
or  cysts  at  the  surface  of  the  brain,  communicating  with  the  arachnoid  space, 
and  in  some  cases  passing  deeply  into  the  hemisphere,  reaching  even  to  the 
ventricle.  Of  103  cases  of  porencephalus  analyzed  by  Audry,  hemii)legia 
was  present  in  68. 

Cortical  sclerosis  and  porencephalus  are  then  the  most  important  anatom- 
ical conditions,  but  the  nature  of  the  causative  processes  is  still  doubtful. 
Gowers  suggests  that  thrombosis  of  the  superficial  veins  and  sinuses  is  a  fre- 
quent cause,  but,  though  this  has  been  found  in  some  cases,  they  are  few  in 
number;  and  it  is  to  be  remembered  that  in  a  considerable  proportion  of  all 
oases  the  disease  sets  in  in  healthy  children.  Strlimpell  has  suggested  that  the 
primarv  condition  is  an  iufiammation  of  the  gray  matter  in  the  motor  cortex 
analogous  to  the  inflammation  of  the  gray  cornua  in  the  spinal  cord — polioen- 
cephalitis. Practically,  it  is  better  to  acknowledge  our  ignorance  of  the  initial 
lesion,  and  there  is  no  section  in  cerebral  pathology  more  in  need  of  careful 
anatomical  work  than  this  group  of  cases. 

Symptoms. — («)  Of  Onset. — An  already  mentioned,  the  disease  sets  in 
with  partial  or  general  convulsions  and  loss  of  consciousness.  The  convul- 
sions may  recur  for  several  days,  during  which  time  the  child  is  unconscious. 
Slight  fever  is  usually  ])resent.  Occasionally  the  hemiplegia  develops  sud- 
denly in  an  api)arently  healthy  chilTl,  without  spasms  or  loss  of  consciousness ; 
in  other  instances  the  paralysis  sets  in  gradually.  The  child  has  usually  begun 
to  walk,  and  the  hemii)legia  is  quickly  noted  as  soon  as  the  child  recovers  con- 
sciousness. The  face  is  not  always  involved.  With  right  hemiplegia  aphasia 
is  not  uncommon,  and  occurred  in  16  cases  of  my  scries,  a  smaller  number 
than   in  the  series  of  Wallenberg,  Gaudard,  and  Sachs. 

(6)  Residiud  Siimptoim. — In  some  instances  the  paralysis  (lisa|>pears  almost 
completelv,  leaving  scarcely  a  trace.  In  one  of  the  KIwyn  cases  the  mental 
<lefeet  an<l  a  slightly  impaired  development  of  the  alTectcd  side  alone  remained 
of  an  infantile  hemii)legia  wlii<-li  had  jiersisted  for  some  time.  The  leg,  as  a 
rule,  recovers  ra|)idly  and  moiv  fully  than  the  arm.  In  a  niajority  of  cases 
there  is  a  chara(!teristic  hemiplegic  gait.     The  i)aralysis  is  most  marked  in  the 


708  ORGANIC  DISEASES    OF    THE  BRAIN. 

arm,  which  is  wasted,  the  forearm  is  flexed  at  right  angles,  the  hand  strongly- 
flexed  at  the  wrist,  and  the  fingers  contracted.  Motion  may  be  completely- 
lost  in  the  forearm  and  hand,  but  is  usually  retained  to  some  extent  in  the 
shoulder  muscles.  Late  rigidity  is  almost  constant,  and  was  the  symptom 
which  suggested  the  name  hemiplegia  spastica  cerebralis  to  Heine,  the  ortho- 
paedic surgeon  who  first  described  these  cases.  The  limbs,  however,  may  be 
quite  relaxed — the  hemipUgie  fla^que.  The  atrophy  may  be  striking,  and  in 
this  disease  we  see  admirable  illustrations  of  the  atrophy  following  a  cerebral 
lesion.  As  a  rule  sensation  is  not  disturbed.  The  reflexes  are  usually- 
increased. 

3Iental  Defects. — One  of  the  most  serious  consequences  of  infantile  hemi- 
]>legia  is  failure  in  mental  development,  in  consequence  of  which  children 
drift  into  the  institutions  for  feeble-minded  children.  There  may  be  idiocy, 
which  is  most  common  when  the  hemiplegia  has  existed  from  birth  or  has 
come  on  at  a  very  early  period  ;  imbecility,  which  may  increase  with  the 
development  and  persistence  of  epilepsy ;  and  a  condition  of  feeble-minded- 
ness,  a  retarded  rather  than  arrested  mental  development. 

Epilepsy  is  one  of  the  most  common  and  distressing  of  the  residual  symp- 
toms of  infantile  hemiplegia.  Of  the  cases  in  my  series,  41  were  subject  to 
convulsive  seizures.  In  other  cases  there  is  only  petit  mal.  The  convulsions 
may  begin  in,  and  be  confined  to,  the  affected  side  without  loss  of  conscious- 
ness— true  Jacksonian  epilepsy — or  there  are  general  convulsions,  usually 
l)eginning  in  the  paralyzed  limbs. 

Post-hemiplegic  movements. — It  was  in  cases  of  this  kind  that  Weir  Mitchell 
first  described  the  post-hemiplegic  movements.  They  are  extremely  com- 
mon, and  were  present  in  34  of  my  series.  There  may  be  only  post-hemi- 
plegic tremor,  in  which  the  arm  or  the  leg  vibrates  gently;  more  commonly 
the  movements  are  inco-ordinate  and  choreiform  ;  or,  lastly,  there  may  be 
athetosis.  In  this  condition,  which  was  described  by  Hammond,  there  is  a 
remarkable  spasm  in  the  paralyzed  limbs,  chiefly  in  the  fingers  and  toes,  and 
in  rare  instancies  in  the  muscles  of  the  face.  The  muscular  movements  are 
involuntary,  often  rhythmical,  and  in  the  hand  the  motions  of  adduction  and 
abduction  and  of  supination  and  pronation  may  follow  each  other  in  orderly 
s(^quence.  The  fingers  are  frequently  hy*perextended  and  spread  far  apart. 
The  movements  are  usually  increased  by  emotion,  and  in  some  cases  persist 
during  sleep.  Athetosis  is  very  much  more  frequent  in  hemiplegia  of  children 
than  in  adults.  In  the  latter  it  may  be  combined  with  hemianaesthesia,  in 
which  case  the  lesion  is  usually  not  cortical,  but  basic,  in  the  neighborhood 
of  the  thalamus  opticus. 

2.  vSpastic  Diplegia. — A  condition  dating,  as  a  rule,  from  birth,  in  which 
there  is  paralysis  with  spasm  of  the  extremities. 

As  stated  in  a  previous  section,  infantile  hemiplegia  occurs  usually  during 
the  first  two  years  of  life.  On  the  other  hand,  the  instances  in  which  both  sides 
are  involved  very  commonly  date  from  birth,  and  constitute  the  most  serious 
of  all   forms  of  so-called  birth-palsies.     In  some  instances  the  arms  are  so 


CEREBRAL    PALSIES    OF    CHILDREN.  709 

slightly  affected  that  there  niav  be  a  doubt  whether  the  case  shuuld  bo  rey;arded 
as  one  of  diplegia  or  paraplegia.  Tiie  relation  of  abnormal  parturition  to  the 
disease  is  the  most  important  })oint  in  its  etiology.  In  very  many  of  the  cases 
the  patients  have  been  born  in  first  labors  or  have  been  instances  of  instru- 
mental delivery.  In  feet  presentation  too  there  is  the  possibility  of  laceration 
and  tearing  of  the  cerebro-spinal  membranes.  Asphyxia  or  convulsions  have 
been  present  in  a  very  considerable  number,  and  it  is  very  common  to  hear  the 
statement  made  in  these  cases  that  the  child  at  birth  was  a  "  blue  baby." 

Morbid  Anatomy. — The  birth-palsies  which  ultimately  induce  the  spastic 
diplegias  and  paraplegias  appear  to  result  more  frequently  from  meningeal 
hemorrhage,  in  which  the  cerebral  cortex  is  damaged,  leading  ultimately  to 
sclerosis  or  atropiiy.  The  frequency  of  meningeal  apoplexy  in  the  new-born 
has  been  demonstrated  by  the  studies  of  Litzmann  and  Sarah  J.  INIcNutt. 
The  hseraorrhage  has  been  found  thickest  over  the  motor  region.  Clinically, 
these  cases  present  the  symptoms  of  asphyxia  or  convulsions,  the  manifesta- 
tions present  in  a  great  majority  of  instances  of  birth -palsies.  It  seems  not 
inireasonable  to  conclude  in  cases  which  recover  and  subsequently  present  signs 
of  motor  disturbance  that  a  similar  though  less  extensive  lesion  has  existed. 
There  are  instances,  however,  which  are  probably  due  to  foetal  meningo- 
encephalitis. The  anatomical  condition  in  spastic  diplegia  in  16  cases  which 
I  collected  from  the  literature  was  either  a  diffuse  atrophy  or  porencephalus. 

Symptoms. — As  stated  above,  the  child  has  usually  been  resuscitated  with 
difficulty  or  has  had  convulsions.  For  some  months  nothing  abnormal  may 
be  noticed  ;  then,  at  an  age  when  the  child  should  begin  to  walk  it  is  found 
not  to  nse  the  limbs  readily,  and  the  mother  may  say  that  she  finds  in  dressing 
the  child  difficulty  in  moving  the  arms  and  legs.  The  child  sits  up  with  diffi- 
culty, or  may  be  quite  unable  to  do  so,  at  the  age  of  two  years,  and  very  often 
the  head  is  not  well  supported,  but  tends  to  fall  forward.  The  rigidity  is 
most  marked  in  the  legs,  and  it  was  this  symptom  which  gave  several  names 
to  the  disease,  such  as  spastic  rigidity  of  the  neic-honi,  essential  contraction,  and 
tonic  contraction  of  the  extremities.  When  made  to  stand  up,  the  child  either 
rests  upon  its  toes  or  upon  the  inner  surfaces  of  the  feet,  with  the  knees  close 
together,  or,  if  the  adductor  spasm  be  very  great,  the  legs  may  be  crossed.  Tiio 
stiffness  of  the  arras  is  rarely  so  marked,  and  is  sometimes  scarcely  noticeable. 
Irregular  movements  of  the  arms  are  not  infrequent,  and  the  child  has  diffi- 
cidty  in  grasping  objects.  The  spasm  and  weakness  may  be  more  pronounced 
on  one  side.  Convulsive  seizures  are  not  uncommon,  and  the  menial  con- 
<lItion  is,  as  a  rule,  defective. 

Associated  with  spastic  <liplegia  there  is  in  certain  instances  the  remark- 
able condition  known  as  bilaleral  athetosis,  in  whicii  there  is  a  coiidjination 
of  spasm,  more  or  less  marked,  with  extraordinary  bizarre  movements  of  the 
nniscles.  The  affection  usually  dates  fi-oiu  iiiCancy.  A  majority  of  the  cases 
are  unable  to  walk.  The  head  is  turned  from  side  to  side,  the  mouth  is  drawn 
and  distorted,  and  there  are  irregidar  movements  of  the  facial  muscles,  hi 
making  any  voluntary  elfort,  or  even  spontaneously,  there  are  extraordinary 


710  ORGANIC  DISEASES    OF    THE   BRAIN. 

movements  of  the  limbs,  and  more  particularly  of  the  arms,  somewhat  like^ 
though  very  much  more  exaggerated  than,  ordinary  post-hemiplegic  athetosis. 
These  vary  extremely,  and  may  produce  complete  disability.  In  other  instances^ 
even  when  very  marked,  the  patient  may  be  able  to  feed  himself.  The  reflexes 
are  increased.  Many  of  the  cases  are  feeble-minded  or  idiotic  :  2  of  the  4  cases 
which  I  have  described  were  intelligent.  Audry,  who  has  published  a  mono- 
graph on  the  subject,  has  collected  over  one  hundred  cases.  There  have  been 
three  autopsies.  In  Kurella's  case  there  were  pachymeningitis  and  bilateral 
lesions  of  the  motor  area.  Dejerine's  patient  had  atrophy  of  the  convolutions 
on  both  sides.     In  my  case  the  brain,  macroscopically,  showed  no  changes. 

3.  Spastic  Paraplegia. — The  paraplegia  cerebralis  spastica  of  Heine  is 
a  common  affection,  due  in  many  cases  to  conditions  similar  to  those  found  in 
spastic  diplegia.  All  grades  of  the  disease  are  met  with,  from  the  pure  spastic 
paraplegia  with  perfect  use  of  the  arm  to  the  most  extreme  bilateral  spasm. 
Evidence  of  the  cerebral  origin  of  the  disease  is  based  upon  the  frequent  coex- 
istence of  idiocy,  imbecility,  and  nystagmus,  and  the  existence  of  cases  of 
spastic  diplegia  in  which  the  paraplegic  symptoms  are  identical.  The  patients 
frequently  present  a  typical  cross-legged  progression.  The  mental  condition 
is  often  better  than  in  the  cases  of  spastic  di})legia.  The  primary  lesion  in 
those  cases  is  in  all  probability  haemorrhage  during  delivery.  In  the  case  of 
Forster  the  post-mortem  showed  a  moderate  grade  of  cortical  sclerosis  with 
sliy-ht  dilatation  of  the  ventricles.  In  the  case  of  Sachs  there  was  meningo- 
ence])halitis  with  atrophy  and  descending  degeneration  of  both  lateral  columns. 

The  diagnosis  of  spastic  diplegia  and  spastic  paraplegia  is  usually  easy, 
but  there  is  a  condition  known  as  pseudo-paralytic  rigidity  which  occurs  par- 
ticularly in  rickets  and  in  chronic  diarrhoea,  the  differences  between  which  may 
be  thus  tabulated  : 

Faeudo-parali/fic  Rigidity.  Spastic  Paralysis;  Di-  and  Paraplegia. 

Follows  a  prolonged  illness.    Is  often  asso-  Usually  exists  from  birth.     History  of  dif- 

ciated  with  rickets,  laryngismus  stridu-  fieult  labor,  of  asi^hyxia  neonatorum,  or 

lus,    and   the    so-called   hydrocephaloid  of  convulsions. 

state. 

Begins  in  hands  as  carpo-pedal  spasm  ;  of-  Arms  rarely  involved  without  legs,  and  not 

ten  contiiied  to  hands  and  arms.  in  such  a  marked  degree. 

Spasms  painful,  and  attempts  at  extension  Usually  painless. 

cause  pain. 

Intermittent  and  of  transient  duration.  Variable  in  intensity,  but  continuous. 

Treatment  of  Cerebral  Palsies.— The  possibility  of  injury  to  the  brain 
must  be  borne  in  mind  in  cases  of  protracted  labor.  Probably  a  long-con- 
tinned  compression  of  the  head  entails  greater  risks  than  the  aj>plication  of 
forceps.  At  the  onset  of  a  case  of  infanti](>  hemiplegia  the  physician,  as  a 
rule,  thiid<s  he  is  dealing  with  a  case  of  ordinary  convulsions,  perhaps  more 
severe  than  usual.  These  should  be  checked  as  quickly  as  possible  by  the 
administration  of  chloroform,  ajid  subsequently  by  the  use  of  bromides. 
Very  little  can   be  done  for  the  paralysis   itself,  which  as  a  rule   improves 


IXSULAB   SCLEROSIS.  711 

irradually,  particularly  in  the  leg.  Complete  reeovery  is,  however,  rare. 
The  main  indications  are  to  favor  the  natural  tendency  to  improve  bv  main- 
taining the  general  nutrition  of  the  child,  to  lessen  the  rigidity  and  contrac- 
tures by  massage  and  passive  movements,  and  to  correct  deformities  bv 
mechanical  or  surgical  measures.  The  aphasia  usually  disappears.  The  epi- 
lepsy is  an  obstinate  feature  which  usually  persists  in  spite  of  all  remedies. 
Prolonged  periods  of  quiescence  are,  however,  not  infrequent.  The  feeble- 
mindedness is  the  most  distressing  symptom,  and  in  too  manv  instances  is 
irrejiarable.  In  others,  with  patient  training  and  care,  a  fair  measure  of 
intelligence  and  self-reliance  may  be  reached.  Of  late  operative  measures 
have  been  advised,  but  when  we  consider  the  anatomical  Condition,  which  is 
almost  invariably  sclerosis,  chronic  meningo-encephalitis,  or  porcncephalus,  it 
is  evident  that  not  very  much  can  be  looked  for.  Certainly  the  recent  review 
by  Starr  of  the  subject  with  special  reference  to  this  point  cannot  be  regarded 
as  at  all  encouraging. 

Insular  Sclerosis  (Sclerose  en  Plaque). 

Definition. — A  chronic  affection  in  \vhich  certain  localized  areas  in  the 
brain  and  cord,  or  more  rarely  in  the  brain  or  cord  alone,  are  replaced  by  con- 
nective tissue.     The  cerebro-spinal  form  is  the  common  type. 

Etiology. — In  a  few  exceptional  instances  two  or  three  members  of  a 
family  have  been  affected.  In  a  majority  of  the  cases  the  symptoms  do  not 
appear  until  adult  life.  The  disease  is,  however,  not  uncommon  in  children, 
and  Prichard  states  that  there  are  more  than  fifty  cases  on  record  in  which 
it  began  before  the  fifteenth  year.  Cold  and  exposure,  mental  shock,  and 
injury  have  been  referred  to  as  possible  causes.  More  inqiortant  are  the 
infectious  diseases,  and  many  cases  have  followed  scarlet  fever,  measles,  and 
dij)htheria.  The  precise  relation  is,  however,  not  known,  though  it  may  be 
that  the  areas  of  localized  induration  follow  the  focal  myelitis  which  has  been 
met  with  as  a  post-febrile  disorder.  In  very  many  cases  the  disease  sets  in 
insidiously  without  any  recognizable  cause.  The  disease  is  most  common  in 
males. 

Morbid  Anatomy. — The  sclerotic  areas  are  widely  distributed  throughout 
the  brain  and  cord,  usually  in  the  white  substance.  They  vary  in  size  from  2 
to  20  or  more  millimetres;  they  are  reddish-gray  in  color,  somewhat  trans- 
lucent, and  cut  with  firmness.  The  cortex  of  the  brain  may  look  quite  nat- 
ural. The  plaques  are  most  abundant  toward  the  basal  ganglia.  In  the  cord 
they  may  be  seen  externally  as  grayish-white  patches,  usually  having  a  greater 
vertical  than  transverse  extent.  There  are  instances  in  which  the  sclerosis  is 
more  diffuse,  involving  in  certain  regions  the  whdle  ihickness  of  the  cord. 
The  foci  of  disease  are  found  in  the  cranial  nerves,  an<l  in  some  instances  in 
the  j)eriphei-al  nerves.  Histologically,  the  diseased  areas  are  seen  to  present  a 
dense  ])lexus  of  new-formed  coiine«'ti\-e  tissue  which  to  a  great  extent  has 
replaced  the  nerve-fd)res.  A  pecuiiai-  Ceature  is  that  while  the  nieihdiary 
sheaths  of  the  nerves  undergo  atrophy,  many  of  the  axi<-cyiitiders   persist  in 


712  ORGANIC  DISEASES    OF    THE   BRAIN. 

a  remarkable  manner,  and  do  not  disappear  until  late  in  the  disease.  The 
blood-vessels  in  the  neighborhood  of  the  patches  are,  as  a  rule,  either  sclerotic 
or  present  fatty  changes.  The  primary  cause  of  the  sclerosis  is  by  no  means 
clear. 

Symptoms. — In  many  cases  the  clinical  history  is  most  distinctive,  but 
atypical  forms  are  by  no  means  uncommon.  Charcot  describes  two  modes  of 
onset :  in  one  the  progress  is  insidious,  characterized  by  headache,  vertigo, 
tired  feelings  in  the  muscles,  and  the  gradual  development  of  inco-ordination 
and  tremor ;  in  the  other  form  the  disease  sets  in  more  abruptly,  sometimes 
with  a  convulsion  or  apoplectic  seizure,  following  which  the  symptoms  of 
tremor  and  weakness  develop.  The  most  important  symptoms  are  the 
following : 

Volitional  Tremor. — This  is  most  marked  as  a  rule  in  the  arms.  When 
the  hands  are  at  rest  on  the  lap  there  may  be  not  the  slightest  movement,  but 
on  attempting  to  pick  up  an  object  there  are  sudden  jerkings  or  an  oscillatory 
tremor.  For  example,  in  taking  a  glass  of  water  the  tremor  increases  to  such 
a  degree  that  by  the  time  the  mouth  is  reached  some  of  the  water  is  spilt,  and 
in  drinking  the  glass  rattles  against  the  teeth.  When  recumbent  the  head 
may  be  perfectly  quiet,  but  on  lifting  it  from  the  pillow  tlie  trembling  at  once 
begins.  .  In  walking  the  shaking  movement  of  the  head  is  sometimes  very 
characteristic.  In  the  early  stage  the  volitional  or  intention  tremor  may  be 
the  only  marked  symptom.  Though  present  in  a  majority  of  the  cases, 
disseminated  sclerosis  may  be  present  without  it.  There  is  more  or  less  inco- 
ordination, and  the  gait  may  be  staggering  and  ataxic.  More  commonly 
there  is  a  spastic  weakness  of  the  muscles  of  the  legs  or  an  ataxic  paraplegia. 
Romberg's  symptom  is  not  usually  present. 

Speech  defects  are  present  in  many  of  the  cases.  There  may  be  a  slight 
indistinctness,  due  to  tremor  of  the  tongue ;  more  commonly  the  words  are 
pronounced  slowly  and  separately,  and  the  individual  syllables  may  be 
accentuated.  This  constitutes  the  scanning,  staccato,  or  syllabic  speech,  which 
is  more  marked  in  this  than  in  any  other  chronic  nervous  affection. 

Eye-symptoms  are  common :  diplopia,  strabismus,  ptosis,  and  dilatation  of 
the  pupil  have  been  frequently  noted.  Optic  atrophy  occasionally  occurs. 
Nystagmus  is  a  very  frequent  symptom,  occurring  in  considerable  proportion 
of  all  cases. 

Sensory  disturbances  are  not  common.  The  i-eflexes,  as  a  rule,  are 
increased,  ])articidarly  when  there  is  a  spastic  condition  of  the  legs.  In  the 
cases  in  which  the  posterior  columns  are  involved  the  reflexes  may  be  abol- 
ished. Tiie  sphincters  are  unaifected.  Epileptic  and  apoplectiform  seizures 
occur  in  some  cases.  Vertigo  is  not  infrequent.  A  gradual  impairment  of 
the  mental  power  is  common,  and  failing  memory,  with  great  complacency 
and  content  under  increasing  helplessness,  is  stated  by  Gowers  to  be  somewhat 
characteristic. 

The  diagnosis  is  easy  in  many  cases,  but  there  are  certain  affections  which 
.simulate  it  very  clo.sely,  and  there  are  remarkable  atypical  cases.     In  the  form 


INSULAR    SCLEROSIS.  713 

in  which  the  spinal  cord  is  chiefly  involved  the  volitional  tremor  may  not  be 
a  marketl  feature,  and  according  to  the  situation  of  the  sclerosed  areas  the 
chief  symptoms  may  be  those  of  a  posterior  spinal  or  of  a  lateral  sclerosis.  In 
children  the  disease  is  frequently  confounded  with  Friedreich's  ataxia,  and  in 
all  probability  some  of  the  hereditary  cases  have  belonged  really  to  this  latter 
disease.  The  ataxia,  the  nystagmus,  and  the  speech-defects  occur  in  both. 
In  Friedreich's  ataxia  the  tremor  is  not  volitional,  and  the  movements  are  of  a 
slower  more  inco-ordinate  nature.  Curvature  of  the  spine  and  contractures 
are  very  much  more  common  in  hereditary  ataxia,  and  the  reflexes  are  usually 
absent,  rarely  increased.  There  are  cases  of  chronic  chorea  in  children  which 
simulate  multiple  sclerosis. 

Anomalous  forms  of  the  disease  are  common.  Among  the  most  puzzling 
cases  are  those  of  the  pseiido- sclerose  en  plaque,  described  by  AVestphal,  in 
which  the  volitional  tremor,  scanning  speech,  and  spastic  condition  were  pres- 
ent, but  no  lesions  were  found  post-mortem.  It  is  possible  that  some  of  these 
were  cases  of  general  paresis.  Hysteria  may  simulate  multiple  sclerosis  verv 
closely.  In  a  ease  regarded  as  hysteria  during  life  Seguin  found  disseminated 
sclerosis. 

The  prognosis  is  unfavorable.  There  are  long  periods  in  which  the  prog- 
ress is  apparently  arrested.  The  cases  last  for  years,  and  finally  become  bed- 
ridden, and  are  carried  off  by  an  intercurrent  affection  or  by  invasion  of  the 
medulla. 

Treatment. — Not  one  of  the  host  of  remedies  which  have  been  recom- 
mended appears  to  have  any  influence  on  tlie  progress  of  the  sclerosis,  but, 
as  in  other  chronic  degenerative  lesions  of  the  cerebro-spinal  system,  prac- 
tically no  treatment  is  of  the  slightest  service.  Electricity  may  be  tried. 
Attention  should  be  j)aid  to  the  general  health,  and  iron  and  arsenic  may 
be  used  if  there  be  aniemia. 

Other  Forms  of  Sclerosis. 

(1)  MiiJARY  Sclerosis,  in  which  there  are  small  grayish-red  spots  scat- 
tered over  the  cortex  or  at  the  line  of  junction  of  the  white  and  gray  matter. 
Sometimes  there  are  multiple  nodidar  projections  on  the  cortex,  consisting  of 
firm,  indurated  tissue.  So  far  as  is  known,  no  symptoms  arc  j)ro(lii(cd  by 
them. 

(2)  Diffuse  Sclerosis,  which  may  involve  an  entire  hemisphere  or  a 
single  lobe — the  lobar  sclerosis  of  the  French — is  a  frequent  condition  in  idiots 
and  imbeciles,  and  cases  are  common  in  asylum  practice.  The  cortical  sclero- 
sis may  be  extensive  and  unilateral,  producing  the  condition  known  as  unilat- 
eral atrophy  of  the  brain,  in  which  the  lateral  ventricle  is  iiiucli  dilated.  The 
symptoms  in  this  condition  depend  very  much  u|)<iii  the  region  aflrctcd.  There 
may  be  considerable  involvement  without  any  paralysis  or  without  lucntal 
impairment.  As  a  rule,  however,  there  is  some  degree  of  imbecility,  and, 
when   the   motor  region   is   involved,    hemiplegia   or  di|)legia. 

(3)  TuiJEROiJS  or   UypeutroI'IIk;  Scuorosis   is  a   remarkable   form    in 


714  ORGANIC  DISEASES   OF   THE  BRAIN. 

-wliich  there  are  upon  the  eouvohitions  areas  of  an  o])aqiie  white  color,  exceed- 
ingly firm  and  hard,  but  which  do  not  necessarily  disturb  the  symmetry  of 
the  gyri.  The  color  is  opaque- white,  and  on  section  they  are  extremely  firm 
and  hard. 

Inflammation  of  the  Brain,  Suppurative  Encephalitis,  Abscess 

OF  Brain. 

Btiolog-y. — Abscess  of  the  brain  is  rarely  primary,  but  follows  infection 
throngli  a  wound  or  extends  from  inflammation  of  a  neighboring  part,  or  the 
infection  is  carried  by  the  blood  from  some  distant  part.  C-ases  occur  occa- 
sionally in  which  it  is  very  difficult  to  assign  a  cause. 

The  conditions  under  which  we  most  commonly  meet  with  suppuration  of 
the  brain  are — 

(!)  Trauma,  particularly  wounds  of  the  head  with  fracture  of  the  cranial 
bones.  Of  50  Guy's  Hospital  cases  analyzed  by  Pitt,  17  were  secondary  ta 
injury  or  disease  of  the  cranium.  The  fractures  were  all  compound.  Occa- 
sionally it  happens  that  abscess  follows  uncomplicated  bruising  without  appar- 
ent laceration  of  the  skin  or  skull.  In  some  of  these  instances  the  infection 
is  conveyed  through  an  unrecognized  fracture  at  the  base  of  the  skull  opening 
into  the  nose  or  ear.  In  other  instances  suppuration  follows  local  disease,  such 
as  periostitis,  nasal  polypus,  or  tumor.  In  all  of  these  cases  meningitis  is  asso- 
ciated with  the  abscess. 

(2)  Extension  from  Ear  Disease. — In  Pitt's  series,  referred  to,  of  56  cases, 
in  18  the  suppuration  followed  otitis  media  or  mastoid  disease.  Of  these  cases, 
9  occurred  on  each  side.  In  two-thirds  of  the  cases  the  abscess  was  in  the  tem- 
poro-sphcn(Mdal  lobe  not  far  from  the  roof  of  the  tympanum.  The  mode  of 
origin  of  the  abscess  in  ear-disease  has  been  much  discussed.  On  this  point 
Pitt  remarks :  "  Where  there  is  healthy  brain-tissue  between  the  abscess  and 
the  bone,  it  is  probable  that  the  infection  has  been  spread  by  the  veins  which 
empty  into  the  superior  petrosal  sinus,  from  the  temporo-sphenoidal  lobe  on 
the  one  hand  and  the  tympanum  on  the  other,  by  means  of  a  septic  phlebitis^ 
or  more  probably  by  means  of  the  perivascular  lymphatics.  Other  veins  run 
direct  from  the  brain  into  the  dura  mater  over  the  petrous  bone.  It  is  worthy 
of  note,  however,  that  in  not  a  single  case  is  there  a  statement  that  the  supe- 
rior petrosal  sinus  was  thrombosed  :  it  was  certainly  examined  in  many  of  the 
cases,  though  ])ossibly  not  in  all.  If  the  mischief  had  usually  spread  by  the 
veins,  and  not  by  the  lymphatics,  we  should  have  expected  thrombosis  to  have 
been  occasionally  noticed.  Frequently  the  brain  adheres  to  the  anterior  sur- 
face of  the  petrous  bone,  over  which  the  dura  mater  is  inflamed,  and  thence 
infection  spreads  by  contact  to  the  cerebral  tissue." 

(3)  Septic  Processes. — It  may  follow  acute  periostitis,  occasionally  abscess 
of  the  prostate,  suppuration  in  the  liver,  and  ulcerative  endocarditis,  in  which 
disease  multiple  foci  of  suppuration  are  not  very  uncommon. 

(4)  In  association  with  diseases  of  the  lungs  and  pleura,  more  particularly 
gangrene,  broncliicctasis,  foetid  bronchitis,  and  occasionally  empyema. 


ABSCESS    OF    THE  BRAIX.  715 

(5)  And,  lastly,  abscess  of  the  brain  may  follow  the  specific  fevers.  Bris- 
towe  has  called  attention  to  it  as  a  seqnence  of  influenza. 

The  largest  number  of  cases  occur  between  the  twentieth  and  the  fortieth 
year,  and  the  condition  is  more  frequent  in  men  than  in  women. 

Morbid  Anatomy. — The  cases  following  trauma  are  frequently  associated 
with  suppurative  meningitis.  The  abscess  may  be  solitary  or  multiple.  In 
acute,  ra[)idly-fatal  cases  after  injury  the  su[)puration  is  not  limite<i,  but  in 
long-standing  cases  the  abscess  is  enclosed  in  a  definite  capsule  which  may 
have  a  thickness  of  from  2  to  5  mm.  The  appearance  of  the  pus  varies  with 
the  age  of  the  abscess.  In  acute  cases  the  pus  has  a  reddish-white  aj)pearance 
and  is  mixed  with  the  debris  of  brain-matter.  In  the  solitary  encapsulated 
abscess  the  pus  is  usually  of  a  creamy  consistence,  with  a  greenish  tint  and 
acid  reaction,  and  may  have  an  odor  not  unlike  sulphuretted  hydrogen.  The 
brain-tissue  about  the  abscess-cavity  is  usually  infiltrated  and  cedcmatous. 
The  size  varies  from  that  of  a  walnut  to  that  of  a  large  orange.  Supjnira- 
tion  may  occur  in  any  district  of  the  brain.  It  is  most  common  in  the  white 
matter  of  the  hemispheres.  In  cases  following  injury  and  in  pyiomia  tiie 
frontal  lobe  and  the  centrum  ovale  are  most  frequently  involved  :  in  those 
following  otitis  media  and  mastoid  disease,  the  temporo-sphenoidal  lobe  and 
the  cerebellum.  In  four-fifths  of  all  cases  the  abscess  is  solitary.  Various 
micro-organisms  have  been  described  in  the  pus  of  cerebral  abscess.  It  may 
be  mentioned,  too,  that  the  oidium  albicans  and  the  actinomyces  have  occa- 
sionally been  found. 

Symptoms. — These  vary  greatly  in  character  and  duration.  Following 
an  operation  or  an  injury,  the  symptoms  may  be  those  of  an  acute  meningo- 
encephalitis, with  rigors,  fever,  headache,  vomiting,  and  delirium.  Wiien 
secondary  to  otitis,  the  irritative  phenomena  may  be  present  for  some  days, 
such  as  restlessness,  severe  headache,  and  aggravated  earache.  Gradually,  as 
the  case  proceeds,  the  mental  processes  become  dulled,  the  patient  grow.s 
drowsy,  and  tlie  pulse  slow  ;  vomiting  may  be  present,  and  optic  neuritis 
is  occasionally  detected.  The  last  symptom  is  not  so  frequent  as  in  tumor. 
Such  symptoms  developing  in  a  case  of  chronic  otorrhoea  are  of  extreme 

gravity. 

In  other  instances  the  course  is  more  chronic  :  there  may  be  a  latent  period, 
with  few  or  no  symptoms,  continuing  for  weeks  or  months,  or  in  some  instances 
prolonged  for  a  year.  During  this  time  the  patient  may  have  no  indication  of 
cerebral  disturbance.  In  other  instances  there  are  irritability,  drowsiness, 
vomiting,  headache,  delirium,  and  convulsions.  The  i)atient  may  become  for- 
getful or  even  ai)hasic,  particularly  when  the  disease  is  on  the  left  side,  aud 
occasionally  there  is  facial  paralysis  or  paresis  of  hot!)  face  and  aim;  or,  after 
the  persistence  for  mouths  of  indefinite  brain  symptoms,  i(  is  not  inlVe(pient  to 
have  a  sudden  outbreak  of  the  most  intense  sym[)lonis— h(  adaclie,  fever,  voui- 
itintr,  and  irradiuillv  increasing  coma. 

Diagnosis. — In  the  acute  cases  following  injury  or  operation  one  is  rarely 
in  doubt,  particularly  when  there  are  severe  headache,  hxal   teuderuess,  clulls, 


716  ORGANIC  DISEASE^S    OF    THE   BRAIN. 

irregular  fever,  and  perhaps  convulsions.  Cerebral  symptoms  following 
chronic  otorrhea,  more  particularly  drowsiness,  irregular  fever,  and  chills, 
should  always  excite  suspicion.  In  these  cases  it  may  be  extremely  difficult  to 
determine  whether  the  suppuration  is  really  within  the  brain,  subdural,  or  in 
the  sinuses.  The  difficulties  are  not  lessened  by  the  knowledge  that  with  otitis 
media  and  with  mastoid  suppuration  there  may  be  symptoms  simulating  men- 
ingitis, or  even  abscess,  such  as  headache,  fever,  and  double  optic  neuritis.  In 
the  long-standing  cases  the  symptoms  may  resemble  those  of  tumor  of  the 
brain,  but  fever  is  often  present,  and  there  may  be  rigors.  It  is  to  be  remem- 
bered that  in  cases  which  last  for  eight  or  ten  months  the  severe  symptoms 
develop,  just  as  happens  sometimes  in  tumors,  with  great  rapidity.  The  local- 
ization of  the  lesion  is  often  uncertain.  A  large  abscess  may  exist  in  a  frontal 
lobe  without  causing  any  symptoms  other  than  mental  dulness.  So  also  in  the 
temporo-sphenoidal  lobe,  the  most  common  seat,  there  may  be  no  focalizing 
symptoms,  but  on  the  left  side  a  large  abscess  is  apt  to  compress  the  speech- 
centre  and  involve  the  motor  areas  for  the  face  and  arm.  In  the  parieto- 
occipital region  there  may  be  hemianopia,  but  an  abscess  of  considerable  size 
may  be  present  without  any  motor  symptoms.  When  the  Rolandic  region  is 
invaded  there  may  be  irritative  symptoms,  such  as  convulsions,  or,  when  the 
centres  are  destroyed,  paralysis.  The  lateral  lobes  of  the  cerebellum  may  be 
almost  destroyed  by  abscess  without  causing  special  symptoms.  When  the 
middle  lobe  is  involved  there  are  inco-ordination  and  a  staggering  gait. 
The  localizing  symptoms  in  the  basal  ganglia  and  in  the  pons  are  very 
uncertain. 

Treatment. — In  cases  following  injury  the  trephine  should  be  applied  and 
the  brain  explored.  Many  recoveries  have  been  reported.  The  most  import- 
ant group  of  cases  is  that  which  follows  ear  disease,  and  the  objects  to  be  aimed 
at  in  treatment  are  so  clearly  laid  down  by  Pitt  in  his  lectures,  already  referred 
to,  that  I  give  them  in  extenso : 

"(a)  In  every  case  to  improve  the  drainage  of  the  ear  by  gouging  away  or 
trephining  the  mastoid  sufficiently  to  open  up  the  horizontal  cells  or  antrum, 
Avhere  pus  is  often  found,  and  to  break  a  hole  through  the  deeper  part  of 
the  posterior  wall  of  the  external  meatus,  so  as  to  allow  no  secretions  to  be 
retained.  The  cavity  should  be  rendered  sweet  and  aseptic  as  soon  as  possible. 
In  a  case  of  otitis  media  it  is  often  desirable  to  carry  out  this  treatment  as  soon 
as  there  is  evidence  of  a  fresh  accession  of  severe  mischief:  should  further 
exploration  be  necessary  later  on,  the  risk  of  infection  from  the  septic  otorrhoea 
will  be  very  much  reduced.  It  is  always  desirable  that  the  external  ear  should 
be  dressed  apart  from  the  other  openings,  if  any  are  made. 

"  (6)  To  expose  the  anterior  surfice  of  the  petrous  bone,  so  as  to  allow  free 
<lrainage  for  any  pus  or  debris  which  may  have  formed  in  connection  with  the 
dura  mater,  which  is  often  inflamed  or  gangrenous.  This  is  best  reached  at  a 
])oint  half  an  inch  above  the  anterior  margin  of  the  external  meatus.  Should 
there  be  any  pus  retained,  some  will  often  be  found  in  the  diploe  of  the  bone 
removed,  in  which  case  the  bone  should  be  broken  away  to  a  quarter  of  an 


TUMORS    OF    THE   BRAIN.  717 

inch  above  and  just  in  iVont  of  the  meatns,  so  as  to  expose  the  most  dependent 
part  of  the  anterior  snrfaee. 

"  (f)  To  drain  the  abscess  from  below  when  possible.  Messrs.  Horsley, 
Macewen,  Barker,  Bergniann,  and  others  have  discussed  the  best  methods  of 
attaining  this  result.  In  the  ease  of  a  temporo-sphenoidal  abscess  tiie  area 
beneath  which  the  pus  will  almost  universally  be  found  may  be  said  to  be 
bounded  anteriorly  and  posteriorly  by  curved  lines  drawn  through  the  tem- 
poro-maxillary  joint  and  the  middle  of  the  mastoid,  running  at  right  angles  to 
the  sagittal  suture,  and  to  extend  from  half  an  inch  to  two  inches  above  the 
meatus.  The  lower  })art  of  this  area  should,  therefore,  be  explored  with  tro- 
car and  canuJa  after  breaking  the  bone  away  or  trephining  a  fresh  hole  and 
opening  the  dura  mater,  unless  special  symptoms  indicate  that  the  abscess  is 
higher  up.  If  the  attempt  to  find  pus  be  unsuccessful,  the  lateral  sinus 
should  be  exposed  and  examined  half  an  inch  directly  behind  the  meatus;  if 
necessary,  the  bone  may  be  further  broken  away  and  the  outer  and  under  part 
of  the  cerebellum  explored  for  abscess." 

Tumors  of  the  Brain. 

New  growths  occur  in  the  brain  at  all  periods  of  life,  and  are  frequent  in 
childhood.  The  maximum  number,  however,  is  in  the  third  decade.  The 
chief  varieties  are  as  follows : 

Tubercle. — This  forms  a  single  or  multiple  growth.  A  solitary  tubercle 
is  not  infrequent,  particularly  in  the  cerebellum.  It  may  reach  the  size  of  a 
walnut  or  even  of  a  hen's  egg.  One-half  of  the  cases  occur  in  the  first  dec- 
ade. The  frequency  is  indicated  by  Starr's  statistics  of  299  cases  of  tumor  in 
j)ersons  under  twenty,  of  which  152  were  tubercle.  There  may  be  groups  of 
irregular  tuberculous  growths  adherent  to  a  greatly-thickened  pia  mater. 

Syphiloma. — This  is  most  common  in  the  hemispheres  and  in  the  pons, 
and,  like  the  tuberculous  tumor,  usually  grows  from  the  pia  mater  or  develops 
on  the  arteries.  Syphilomata  are  usually  small  and  rarely  reach  the  size  of  a 
walnut.  Thev  are  often  multiple.  They  occur  much  more  frequently  in  the 
acquired  than  in  congenital  syphilis. 

Glioma  and  Neuro-glioma. — These  constitute,  in  reality,  a  variety  of 
sarcoma  developing  from  the  elements  of  the  neuroglia.  They  vary  very 
greatlv  in  appearance.  Some  of  them  grow  slowly,  are  firm,  hard,  and  dif- 
ficult to  distinguish  from  an  area  of  sclerosis,  altering  very  slightly  the  por- 
tion of  brain  involved  ;  others  grow  more  ra]>idly  and  are  soft  and  highly 
vascular.  While  verv  many  of  them  consist  of  a  fibriUary  network  and 
branching  cells,  there  are  others,  called  neuro-gliomata  by  Klcbs,  wliich  have 
enormous  spindle-cells  with  single  large  nuclei,  and  others  not  unlike  the 
large  ganglion-cells.  Some  of  these  large  spindle-cells  undergo  a  nniMrkable 
vitreous  transformation.  The  slow  growth  of  ccrfaiii  gliouiMla  is  a  point  of 
great  interest.  Ilughlings  Jackson  has  rei)orted  an  iii^laiuv  in  which  the 
symptoms  ])ersisted  for  more  than   ten  years. 

Sarcomata,  round-  and  spindle-celled  forms,  are  not  infre<juent,  and  con- 


718  ORGAA^IC  DISEASES    OF    THE   BBATN. 

stitiite  the  largest  and  most  diffusely  infiltrating  of  the  cerebral  tumors.  They 
may  develop  in  the  substance  of  the  brain  itself,  in  the  membranes,  or  invade 
from  the  bone. 

Cancer  is  usually  secondary  to  disease  in  other  parts,  and  may  be  multiple. 
Primarv  cancer  of  the  brain  is  rare.  It,  as  well  as  the  sarcoma  growing  from 
the  membranes,  may  perforate  the  bone  and  appear  externally,  forming  the 
so-called  "  fungus  hfematodes." 

Cysts  occur  in  all  parts  of  the  brain,  particularly  about  the  basal  ganglia, 
where  thev  resu.lt  from  changes  in  clots.  Other  forms  occur  between  the  mem- 
branes and  the  brain-substance.  They  may  result  from  the  breaking  down  of 
a  tumor.  Porencephalus  follows  congenital  atrophy  or  haemorrhage  at  birth, 
or  may  be  due  to  a  developmental  defect.  Dermatoid  cysts  have  occasionally 
been  found.  Cystic  disease  of  the  choroid  plexuses  is  extremely  common,  and, 
unfortunately,  the  word  "  hydatid  "  has  been  applied  to  them,  but  they  must 
not  be  mistaken  for  the  true  hydatid  or  echinococcus  cyst. 

Parasitic  Cysts  are  not  infrequent,  particularly  in  certain  countries. 
Cysticerci  may  be  numerous  throughout  the  brain.  When  in  the  substance 
they  do  not  attain  a  large  size,  but  in  the  ventricles  the  bladder-like  cysts  may 
be  as  large  as  a  walnut.  The  echinococcus  cysts  are  most  frequent  in  the 
hemispheres,  and  may  attain  a  large  size. 

Other  varieties  of  growths  are  met  with,  as  fibrous  tumors,  which  usually 
develop  from  the  membranes ;  bony  growths,  which  are  not  at  all  infrequent 
in  the  falx  and  tentorium  ;  psammoma  and  cholesteatoma  are  occasionally  met 
with  y  fatty  tumors  have  been  found  on  the  corpus  callosum  ;  and,  lastly,  an- 
eurisms, which  have  been  elsewhere  considered. 

Symptoms. — New  growths  within  the  skull  may  produce  symptoms  by 
direct  invasion  and  destruction  of  the  brain-tissue,  as  in  sarcomata,  or  by 
local  pressure,  as  in  the  case  of  fibromata  growing  from  the  dura.  Irritative 
effects  are  very  frequently  seen  either  inducing  a  meningitis  or  stimulating 
in  a  morbid  manner  the  excitable  region  of  the  brain.  Mechanical  effects 
of  tumors  are  also  very  important,  acting,  in  the  first  place,  by  increasing 
materially  the  intracranial  pressure.  The  effect  may  be  more  manifest  at  a 
distance  than  in  the  immediate  vicinity  of  the  growth.  At  the  base  of  the 
brain  and  in  the  neighborhood  of  the  third  ventricle  the  tumors  may  interfere 
greatly  with  the  circulation  in  the  venae  Galeni,  causing  hydrocephalus.  Large 
tumors  may  cause  by  their  pressure  marked  atrophy  of  the  cranial  bones  or 
even  a  condition  of  softening — craniotabes.  The  symptoms  may  be  divided 
into  two  classes — general  and  focal. 

(1)   General  Symptoim. — The  most  important  of  these  are  the  following : 

Headache,  which  may  be  diffuse  or  localized  in  one  part.  When  very  localized 
there  may  be  a  tenderness  on  pressure,  and  the  slightest  jar  greatly  increases 
the  pain.  Occasionally  the  pain  radiates  in  the  branches  of  the  cervical  nerves 
or  there  are  severe  neuralgic  pains  in  the  face.  The  greatest  intensity  of  the 
pain  may  not  corresjwnd  to  the  region  of  the  tumor,  and  there  are  cases  in 
wiiich  the  tumor  of  the  cerebellum  has  been  associated  with  great  pain  in  the 


TUMORS    OF    THE   BE  A IX.  719 

frontal  region.  Headaches  of  greater  severity  and  persistence  are  met  with  in 
brain-tnmor  than  in  any  other  condition.  In  some  instances  there  is  only  a 
<lull,  uneasy  sensation,  which  scarcely  amounts  to  pain  except  on  exertion  or 
on  emotion.  Though  continuous  as  a  rule,  tiiere  may  be  paroxysms  of  much 
greater  intensity  which  are  sometimes  nocturnal. 

()l)tic  neuritis  occurs  in  four-fifths  of  all  cases,  usually  double,  but  some- 
times it  is  found  only  in  one  eye.  It  is  independent  of  the  size  of  tiie  tumor, 
and  in  large  growths  which  develop  slowly  it  may  not  be  present.  On  the 
other  hand,  it  may  occur  with  very  small  tumors,  more  particularly  at  the 
base.  It  is  very  important  to  bear  in  mind  that  a  high  grade  of  optic  neuritis 
may  exist  for  some  Umc  without  special  impairment  of  vision,  so  that  the  con- 
ilition  must  be  carefully  sought  for.  As  a  rule,  atrophy  of  the  nerve  super- 
venes, with  great  impairment  of  vision  or  total  biintlness. 

Vomiting  is  a  very  common  symptom,  and  occurs  without  nausea  and 
without  definite  relation  to  the  taking  of  food.  It  is  more  fre<juent  in  tumors 
about  the  central  ganglia  and  the  base.  It  is  a  very  pronounced  symptom  in 
intracranial  growths  in  children. 

Convulsions  are  frequent,  and  are  either  general,  resembling  true  epilepsy, 
or  localized,  the  so-called  Jacksonian  fits.  Petit  mal  is  rarely  present.  Occa- 
sionally there  is  tetanic  rigidity  of  certain  groups  of  muscles. 

Mental  disturbance  may  be  manifested  in  the  dull,  stupid  condition  of  the 
patient,  or  he  may  act  in  an  odd,  unnatural  manner.  Occasionally  there  are 
hallucinations  and  delusions,  which  may  be  so  marked  that  the  patient  is  com- 
mitted to  an  asylum.  Occasionally  symptoms  resembling  hysteria  may  dcveloj). 
In  the  final  stages  coma  is  common.  Vertigo  is  a  very  in)iK>rtant  symptom, 
often  associated  with  the  vomiting.  It  is  most  frequent  in  tumors  at  the  base 
and  of  the  cerebellum.  It  is  particularly  manifested  as  the  patient  rises  from 
the  recumbent  posture.  Fever  is  present  in  some  rapidly-growing  tumors, 
and  the  local  temperature  of  the  head  may  increase,  and  in  many  instances  the 
thermometer  has  registered  higher  on  the  surface  nearest  the  site  of  the  tumor. 
A  slow  pulse  is  not  infrequent,  and  sometimes  there  is  irregularity.  Toward 
the  close  Cheyne-Stokes  breathing  may  be  present. 

(2)  Focal  Symptoms. — (d)  The  motor  area.  The  sym])t()ms  may  be  cither 
irritative  or  destructive  in  character.  In  the  lower  third  of  the  motor  region 
the  irritative  effects  of  a  growth  may  be  manifested  in  s})asin  localized  to  the 
muscles  of  the  face  or  of  the  tongue.  In  the  middle  region  containing  the 
<'cntres  fi)r  the  arm  and  hand  the  irritation  may  cause  sj)asin  in  (Iu>  lingers,  in 
the  liml)s,  in  the  muscles  of  the  wrists,  or  in  those  of  the  shoulder  ;  while  in 
the  upper  third  of  the  motor  area  the  effects  may  be  manifested  in  spasm 
beginning  in  the  toes  or  the  musdes  of  the  foot  or  in  those  of  the  leu.  With 
these  there  are  usuallv  important  sensory  (iisturbanees.  sneh  as  niimbiiess  and 
tingling  or  aniesthcsia,  which  may  be  felt  befi)re  the  spasm  oeenrs.  Convul- 
sive seizures  localized  in  this  way  to  certain  gron|)s  and  extending  are  known 
as  Jacksonian  spasms,  and  they  are  strictly  comparable  to  those  which  may  bo 
induced  bv  electrical  stinuilation  oftlie  eoitex.      In  the  stndv  ofilie  cases  it  is 


720  ORGANIC  DISEASES    OF    THE   BBAIN. 

of  the  utmost  importance  to  determine  the  region  first  affected  by  the  numb- 
ness, tingling,  and  spasm.  Together,  these  constitute  what  Seguin  has  termed 
the  signal  symptom.  The  spasm  is  not  necessarily  accompanied  by  sensory 
disturbance.  The  effects  of  local  irritation  in  the  cortex  radiate  from  the 
point  of  origin,  involving  successive  groups  of  motor  cells,  and  often  inducing 
an  orderly  sequence  of  spasms  in  the  muscles  which  they  control ;  thus,  an  irri- 
tative lesion  in  the  lower  third  of  the  motor  area  causes  first  spasm  of  the  facial 
muscles,  then,  if  it  increase  in  intensity,  of  the  centres  above  this  point  con- 
trolling the  arm  and  hand,  and  may  ultimately  reach  the  centres  higher  in  the 
convolutions  which  control  the  muscles  of  the  leg.  Following  the  spasm  there 
may  be  anaesthesia  and  frequent  inability  to  use  the  muscles  which  have  been 
convulsed — paresis.  In  studying  the  localized  convulsions  from  tumor  three 
special  points  are  to  be  observed  :  first,  the  starting-point  of  the  spasm  or 
of  the  preliminary  sensory  symptoms ;  second,  the  order  of  march  of  the 
spasm ;  and  third,  the  condition  of  the  parts  after  the  spasm  has  passed, 
whether  there  be  any  paresis  or  anaesthesia. 

Destructive  lesions  in  the  motor  areas  cause  a  paralysis  which  is  often  pre- 
ceded by  the  localized  convulsion.  It  is  frequently  monoplegic  in  type, 
affecting  the  face  or  face  and  arm  together,  more  rarely  the  leg  alone.  The 
paralysis  is  usually  slow  and  gradual  in  its  onset.  In  large  growths  involving 
the  internal  capsule  the  hemiplegia  may  be  complete  and  may  be  accompanied 
with  hemiauEesthesia.  Tumors  of  the  pons  may  cause  paralysis  of  the  arm  and 
leg  on  one  side  and  of  the  face  on  the  opposite. 

A  not  infrequent  symptom  in  tumors  situated  in  the  motor  area  on  the  left 
side  is  asphasia  from  involvement  of  the  third  left  frontal  convolution.  The 
tactile  and  muscular  senses  are  also  impaired  in  cortical  lesions  in  the  motor 
area,  and  should  always  be  carefully  tested. 

(6)  Prefrontal  area.  Tumors  in  this  region  may  not  present  any  localizing 
symptoms  whatever.  The  general  symptoms  are  usually  well  marked,  and 
stupor  and  gradual  impairment  of  the  mental  powers  are  not  infrequent.  On 
the  orbital  surface  the  olfactory  bulb  may  be  destroyed,  producing  loss  of  the 
sense  of  smell,  and  in  many  cases  the  growth  of  the  tumor  backward  involves 
the  motor  centres  and  causes  spasm  or  convulsion,  or  on  the  left  side  aphasia. 

(c)  In  the  parietal  lobe  tumors  may  attain  some  size  without  causing  any 
local  symptoms.  Sensory  changes  have  been  noted  in  many  cases,  particularly 
l)ar8esthesia  and  partial  anaesthesia  on  the  opposite  side  of  the  body.  In  the 
lower  portion  of  the  parietal  region  involvement  of  the  angular  and  supra- 
marginal  gyri  on  the  left  side  causes  a  form  of  sensory  aphasia  in  which  the 
patient  is  unable  to  recognize  written  or  printed  words.  Another  important 
localizing  symptom  in  tumors  which  invade  deeply  the  white  matter  of  the 
parietal  lobe  is  hemianopia,  due  to  involvement  of  the  visual  tract. 

(r/)  Tumors  of  the  occipital  lobe  cause  no  motor  disturbance,  but  produce 
hemianopia  on  the  side  opposite  the  lesion.  More  rarely  the  irritation  of  a 
new  growth  causes  hallucinations  of  light  or  of  sight,  which  are  often  followed 
by  spasms  or  convulsions.     I^arge  growths  in  the  left  hemisphere  may  be 


TUMORS    OF    THE   BRAIN.  721 

associated  with  word-blindness  and  a  condition  known  as  mind-blindness. 
Passing  forward,  the  tumors  may  invade  the  internal  capsule,  causing  hemi- 
plegia and  hemianesthesia. 

{e)  In  the  temporal  lobe  tumors  may  reach  a  large  size  without  causing 
any  symptoms.  In  the  left  hemisphere  invasion  of  the  first  and  second  gyri 
is  associated  with  word-deafness,  and  not  infrequently  a  condition  of  para- 
phasia in  which  words  are  misplaced.  There  are  a  few  eases  which  indicate 
that  involvement  of  the  uncinate  convolution  and  the  hippocamj)us  causes  dis- 
turbance in  the  sensations  of  taste  and  smell. 

(/)  Tumors  of  the  insula  cause  symptoms  which  are  chicHy  indirect ;  thus, 
involvement  of  the  arteries  as  they  pass  over  the  convolutions  is  followed  by 
softening  in  the  motor  area  and  mono-  or  hemiplegia.  Paraphasia,  in  which 
words  are  misplaced,  is  a  frequent  symptom,  due  to  interruption  of  the  asso- 
ciation tracts  uniting  the  auditory  perceptive  centres  and  Broca's  convolution. 
Owing  to  the  close  proximity  of  the  internal  capsule  to  the  island  of  Rcil 
hemiplegia  is  not  infrequent  from  ])ressure. 

((/)  Basal  ganglia.  Limited  growtiis  in  the  nuclei  of  the  corpus  striatum 
do  not  necessarily  cause  symptoms.  Tumors  of  the  thalamus  opticus  are  also, 
if  small,  latent  in  their  growth,  but  when  large  they  involve  the  fibres  of  the 
optic  radiation  and  the  internal  capsule,  causing  iiemianopia  and  hemi- 
ansesthesia.  By  far  the  most  important  symptoms  of  tumor  in  this  region 
are  those  produced  by  invasion  of  the  internal  capsule  which  lies  between 
these  ganglia.  The  anterior  part  of  the  capsule  may  be  invaded  without 
symptoms.  Destruction  of  the  central  portion  causes  hemiplegia,  and  of  the 
posterior  portion  hemianesthesia  and  hemianopia. 

Tumors  of  the  corpora  quadrigemina  are  rarely  limited,  l)ut  involve  the 
crura  cerebri  as  well.  Ocidar  symptoms  are  most  frequent — loss  of  pupil 
reflex,  nystagmus,  and  motor-ocular  paralysis.  There  may  be  involvement  of 
the  third  nerve  as  it  passes  through  the  crus,  causing  motor-oeuli  palsy  on 
(me  side  and  hemiplegia  on  the  other.  Oi)tic  neuritis  is  an  early  symj)tom, 
and  hydrocephalus  from  pressure  very  freciuently  occurs. 

(/<)  Tumors  of  the  pons  and  medidla.  The  symptoms  are  chiefly  tiiose  of 
involvement  of  the  nerves  emerging  from  this  region.  In  the  pons  the  ])yra- 
midal  tracts  and  nerves  may  be  involved  separately  or  together.  Of  hi  cases 
analyzed  by  Mary  Putnam  Jacobi,  there  were  1.3  in  which  the  cranial  nerves 
were  involved  alone,  13  in  which  the  limits  were  afTc(;ted,  and  in  26  there 
were  hemi|)legia  and  involvement  of  the  nerves  :  22  of  tiie  latter  had  what  is 
known  as  alternate  i)aralysis;  that  is  to  say,  involvement  (»f  the  cranial  nerves 
on  one  side  and  of  the  limbs  on  the  opposite  side  of  tin'  liody.  A  tumor 
growing  in  the  lower  region  of  the  pons  invctKcs  the  sixth  ihtvc,  producing 
internal  strabismus;  the  seventh  nerve,  causing  facial  paralysis;  and  the 
auditory  nerve,  causing  deafness,  sometimes  willi  vertigo.  Conjuate  devia- 
tion of  the  eves  to  the  side  o|)|)osite  tlie   fa<'iiil   paralysis  also  oeciiiv. 

Tumors  of  the  medulla  involve  the  cranial  nerves  alone,  or  cause  a  com- 
bination of  hemi|)legia  with  paralysis  <jf  these  nerves.  Iiiit:ilive  elVecN  in  the 
Vol..  r.— 46 


722  ORGANIC  DISEASES    OF    THE   BBAIN. 

territory  of  the  ninth,  tenth,  and  eleventh  nerves  are  usually  present,  and 
there  may  be  difficulty  in  swallowing,  irregular  action  of  the  heart,  irregular 
respiration,  vomiting,  and  retraction  of  the  head  and  neck.  The  unsteadiness 
of  the  gait  is  frequent,  and  there  may  be  well-marked  ataxia.  Sensory  symp- 
toms, such  as  numbness  and  tingling,  are  present;  toward  the  close  convul- 
sions may  occur. 

(/)  Cerebellum.  Extensive  disease  may  exist  in  either  hemisphere  without 
causing  symptoms.  When  the  middle  lobe  is  involved  there  are  very  charac- 
teristic features,  of  which  the  following  are  the  most  important  : 

Vertigo,  which  is  more  frequent  in  disease  of  the  cerebellum  than  in  any 
other  part  of  the  brain.  The  giddiness  may  be  of  a  most  distressing  nature, 
and  the  patient  may,  on  attempting  to  stand,  complain  of  a  sense  of  swimming 
in  the  head.  It  is  frequently  present  with  severe  headache,  and  may  be  asso- 
ciated with  nausea  and  vomiting.  The  semicircular  canals  are  known  to  have 
their  central  relations  in  the  cerebellum,  and  the  giddiness  is  probably  due  to 
disturbance  of  the  central  mechanism  of  equilibration. 

Headache  is  more  common  in  tumors  of  the  cerebellum  than  in  other 
regions,  and  is  usually,  but  not  necessarily,  occipital. 

Cerebellar  ataxia  is  characterized  by  an  irregular  staggering  gait,  the 
patient  reeling  to  and  fro  like  a  drunken  man.  It  is  quite  unlike,  and  cannot 
be  confounded  with,  the  gait  of  locomotor  ataxia.  When  the  growth  invades 
the  middle  peduncle  of  the  cerebellum,  the  tendency  as  a  rule  is  to  fall  to  the 
same  side.     Sometimes  the  patient  falls  forward,  at  other  times  backward. 

Other  less  constant  but  suggestive  symptoms  are  optic  neuritis,  neuralgic 
pains  in  the  region  of  the  neck  and  occiput,  nystagmus,  pressure  symptoms  on 
the  medulla,  progressive  coma  due  to  distension  of  the  lateral  ventricles,  and 
lastly  bilateral  rigidity  from  pressure  on  the  motor  paths. 

Diagnosis. — From  the  general  symptoms  the  existence  of  a  tumor  can 
generally  be  determined.  Tiie  combination  of  severe  headache,  optic  neuritis, 
and  vomiting,  })articularly  if  the  latter  be  causeless,  are  especially  significant. 
Neither  in  uraemia,  lead-poisoning,  nor  anaemia — conditions  in  which  we  some- 
times have  optic  neuritis — is  the  headache  of  such  an  agonizing  character  as  it 
commonly  is  in  brain-tumor.  In  these  cases,  when  focal  symptoms  are  absent, 
for  a  time  doubt  may  exist,  and  I  have  known  several  instances  of  chronic 
Bright's  disease  in  which  the  headache  and  the  intense  neuro-retinitis  led  at 
first  to  the  Suspicion  of  brain-tumor.  The  urinary  and  the  cardio-vascular 
changes  in  these  cases  are,  however,  always  pronounced. 

The  focal  symptoms  already  referred  to  are  of  great  value  in  determining 
the  existence,  as  well  as  in  defining  the  location,  of  the  new  growth.  It  must 
not  be  forgotten  that  focal  symptoms,  such  as  Jacksonian  epilep.sy,  may  occur 
with  general  paresis.  The  diagnosis  from  abscess  of  the  brain  has  already 
been  referred  to.  The  syphilitic  tumors  are  the  most  important  of  all  to  diag- 
nose, as  medicinal  treatment  is  of  such  importance.  Careful  examination 
should  l)e  made  for  traces  of  old  sores,  and  the  patient  should  at  least  re- 
ceive the  benefit  of  any  doubt. 


CHRONIC  HYDROCEPHALUS.  723 

Prognosis. — In  a  majority  of  oases  this  is  unfavorablo.  Ciiinimata  are 
alone  amenable  to  treatment.  Tuberculous  growths  have  been  known  to 
undergo  calcification.  The  gliomata  and  fibromata  may  persist  for  years. 
Oases  have  been  reported  in  which  Jacksonian  epilepsy  has  continued'  for  from 
ten  to  fourteen  years.  The  more  rapidly-growing  sarcomata  ])rovc  fatal,  as  a 
rule,  within  from  six  to  eighteen  months.  Death  may  be  sudden,  particularly 
in  growths  near  the  medulla:  more  frequently  it  is  due  to  coma,  in  conse- 
quence of  the  gradual  increase  in  the  intracranial  pressure. 

Treatment. — (a)  Medical. — Whenever  a  suspicion  of  syphilis  exists,  the 
iodide  of  potassium  and  mercury  should  be  given,  more  particularly  the  for- 
mer, in  increasing  doses.  The  results  are  sometimes  most  satisfactory.  In 
tuberculous  growths  the  chances  of  healino;  are  very  slioht,  thou<>;h  there  are 
instances  in  which  the  symptoms  have  yielded.  The  headache  is  usually  the 
symptom  for  which  the  patient  seeks  relief,  and  the  ice-bag  may  be  applied, 
or  in  the  case  of  occipital  headache  the  Paquelin  cautery  to  the  back  of  the 
neck.  In  the  syphilitic  cases  the  pain  is  often  relieved  promptly  with  the 
iodide.  Chloral  and  cannabis  Indica  may  be  used,  but  in  the  severer  forms 
morphine  alone  gives  relief.  The  bromides  are  not  of  much  service  in  reliev- 
ing the  .symptoms  of  brain-tumor. 

(6)  Surgical. — The  cases  suitable  for  operation  are  limited  in  number. 
Some  tumors  are  quite  inaccessible,  and  in  others  which  are  accessible  the 
invasion  of  adjacent  parts  contraindicates  removal.  The  most  satisfactory 
forms  are  those  which  grow  from  the  membranes  and  only  comjircss  the 
brain-substance,  as  in  the  case  reported  by  Keen.  The  impunity  with  which 
large  sections  of  the  calvarium  can  be  removed  and  the  cortex  cerebri  exposed 
warrants  the  exploratory  operation  in  suitable  cases. 

Chronic  Hydrocephalus. 

Diagnosis. — A  condition,  congenital  or  acquired,  in  which  there  is  a  great 
accumulation  of  fluid  in  the  ventricles  of  the  brain,  usually  with  enlargement 
of  the  head.  An  external  hydrocephalus  is  described  in  which  the  fluid  is  in 
the  arachnoid  sac,  but  this  is  met  with  in  ca.ses  of  atr()])hy  of  the  brain,  the 
.so-called  Iii/drocephalas  ex  vacuo.  In  a  few  instances  a  .sacculated  exudation 
occurs,  forming  a  meningeal  cv.st.  In  cases  of  extreme  enlargement  of  the 
lateral  ventricles  the  brain-substance  may  be  so  thinned  at  the  cortex  that  the 
ventricular  and  arachnoid  .spaces  communicate.  Cases  of  true  hydrocephalus 
mav  be  divided  into  two  group.s — the  congenital  or  infantile  and  the  accpiired. 

(1)  Congenita li  OR  Infantile  Hydrocephai.u.s. — The  condition  nuiy 
develop  in  the  foetus  and  the  enlarged  head  may  ob.struct  labor.  No  reason- 
able ex|)lanation  has  been  offered  of  its  occurrence.  Several  children  in  suc- 
cession have  been  known  to  be  affected  in  the  .same  family.  INIuch  uuu-v  fre- 
quently nothing  abnormal  is  noted  at  the  time  of  l)irth,  but  gradually  the 
head  enlarges. 

The  anatomical  condition  is  very  striking.  The  ventricles,  particularly 
the  lateral,  are  enormously  di.stend(!d.     The  ependyma  is  clear,  occasionally  a 


724  ORGANIC  DISEASES    OF   THE  BRA  IX. 

little  thickened  and  granular ;  the  veins  are  large  ;  the  choroidal  plexuses  are 
vascular,  sometimes  sclerotic,  but  often  natural-looking.  The  third  ventricle 
is  enlarged,  the  aqueduct  of  Sylvius  dilated  and  fiuinel-shaped,  and  the  fourth 
ventricle  may  be,  but  is  not  always,  distended.  The  fluid,  which  may  reach 
several  litres  in  amount,  is  limpid  and  contains  traces  of  albumin  and  salt, 
sometimes  urea  and  cholesterin.  The  cortex  cerebri  is  stretched  and  thin. 
Over  the  Rolandic  region  there  may  be  a  layer  of  not  more  than  2  or  3  mm. 
in  thickness,  and  all  trace  of  sulci  and  convolutions  is  obliterated.  The  basal 
ganglia  are  compressed  in  the  floor  of  the  sac.  The  most  striking  feature  in 
the  appearance  of  the  child  is  the  great  enlargement  of  the  skull,  which  in  a 
child  of  three  or  four  years  of  age  may  reach  twenty-five  or  even  thirty  inches 
in  circumference,  and  looks  enormous  in  proportion  to  the  size  of  the  face. 
The  bones  of  the  cranium  are  extremely  thin,  the  sutures  widen,  and  Wormian 
bones  develop  in  them.  The  subcutaneous  veins  are  usually  large  and  well 
marked.  The  orbital  plates  of  the  frontal  bone  are  depressed,  causing  exoph- 
thalmos, and  the  eyeballs  cannot  be  completely  covered  by  the  lids.  Tlie 
fluctuation  Avave  may  sometimes  be  obtained,  and  Fisher's  brain-murmur  is 
often  present.  The  child  learns  to  walk  late,  and  in  extreme  cases  the  legs 
become  feeble  and  spastic.  The  reflexes  are  increased,  and  occasionally  con- 
vulsions occur.  The  mental  condition  is  variable:  the  child  may  be  bright, 
but  as  a  rule  there  is  some  grade  of  imbecility  and  the  child  learns  to  talk 
slowly.  Nystagmus  frequently  develops,  and  in  the  congenital  cases  death 
usually  occurs  within  the  first  four  or  five  years.  Occasionally  the  disease  is 
arrested  and  the  patient  may  reach  adult  life,  as  in  the  case  of  Cardinal, 
described  by  Bright,  who  lived  to  the  age  of  twenty-nine,  and  whose  head  was 
translucent  when  the  sun  was  shining  upon  it. 

The  diagnosis  is  rarely  difficult.  In  moderate  enlargement  the  disease 
may  be  confounded  with  the  rickety  head,  which,  however,  is  distinguished 
by  the  squarer  outline,  the  flattened  vertex,  the  absence  of  bulging  of  the 
fontanelles,  and  more  particularly  by  the  presence  of  other  rickety  mani- 
festations. 

(2)  Acquired  Hydrocephalus. — In  the  adult,  distension  of  the  ventricles 
is  met  with  most  commonly  as  a  result  of  interference  with  the  circulation  in 
the  straight  sinus  or  in  the  vense  Galeni.  In  a  majority  of  instances  there  is 
oedema  at  the  base.  In  other  instances  the  foramen  of  Magendie,  by  which 
the  ventricles  communicate  with  the  spinal  meninges,  becomes  closed,  or  the 
foramen  of  Monro  is  occluded,  or  the  passage  from  the  third  to  the  fourth 
ventricle  is  closed  by  tumor.  A  rare  cause  is  meningitis,  particularly  the 
epidemic  cerebro-spinal  form,  after  which  hydrocephalus  has  been  known  to 
develop.  There  are  other  instances  in  which  the  inflammation  is  a  meningo- 
ependymitis.  In  rare  instances  the  hydrocephalus  develops  in  the  adults  with- 
any  observable  cause.  The  skull,  as  a  rule,  docs  not  enlarge  in  the  hydro- 
cephalus of  adults,  though  occasionally  the  sutures  may  separate  and  there  is 
some  increase  in  size.  In  the  cases  associated  with  tumor,  even  when  the  dis- 
ease begins  early  in  life,  there  may  be  no  enlargement  of  the  skull.     In  the 


CHEOXIC   HYDROCEPHALUS.  725 

case  of  a  girl  aged  sixteen,  blind  from  her  third  year,  the  ventricles  were 
enormously  distended,  owing  to  the  presence  of  a  tumor  in  the  third  ventricle. 
The  head  was  not  at  all  enlarged. 

The  symptoms  of  acquired  hydrocephalus  arc  very  variable.  Headache, 
attacks  of  somnolence,  progressive  optic  neuritis  leading  to  atrophy  and  blind- 
ness, have  been  i'requently  present. 

The  diagnosis  is  rarely  possible.  Gradually  progressing  optic  neuritis 
without  focalizing  symptoms,  severe  headache,  stupor,  and  attacks  of  somno- 
lence, are  suggestive  symptoms.  One  patient,  whose  case  I  described,  was 
imconscions  for  more  than  three  months. 

Treatment. — ^Medicines  are  useless  in  this  condition.  Gradual  compres- 
sion may  be  made  by  means  of  broad  plasters  applied  so  as  to  cross  each 
other  on  the  vertex,  while  others  are  made  to  encircle  the  head.  Puncture  of 
the  distended  ventricle  has  frequently  been  made,  and  when  pressure  symp- 
toms are  present  this  is  a  rational  operation.  The  aspirator  needle  may  be 
inserted  at  the  outer  angle  of  the  anterior  fontanelle.  Only  a  few  ounces 
should  be  removed  at  a  time :  convulsions  and  acute  meningitis  have  been 
known  to  follow.  Quincke  recommends  and  has  practised  in  acute  as  well 
as  chronic  hydrocephalus,  puncture  of  the  subarachnoid  sac  beween  the  third 
and  fourth  lumbar  vertebne.  The  spinal  cord  cannot  of  course  be  injured  at 
this  point,  and  the  fluid  can  be  removed  more  slowly  and  with  much  less 
danger  of  collapse. 


SYPHILIS  OF  THE  NERVOUS  SYSTEM. 

By  HORATIO  C.  WOOD. 


Syphilitic  Disease  of  the  Brain. 

Etiology. — Cerebral  syphilis  is  usually  a  late  phenomenon,  but  may 
appear  within  three  months  after  primary  infection.  I  have  myself  seen  it 
at  every  period  from  one  to  thirty  years.  It  is  especially  liable  to  develop 
when  the  secondary  symptoms  have  not  been  severe,  and  in  common  with 
other  observers  I  have  repeatedly  seen  it  when  both  primary  and  secondary 
symptoms  have  been  so  slight  as  to  escape  observation  on  the  part  of  the 
victim.  Inherited  syphilis  is  less  prone  to  attack  the  nervous  system  than  is 
acquired  syphilis,  but  cerebral  gummata  may  develop  during  intra-uterine  life 
and  at  any  time  subsequently  ;  indeed,  nervous  syphilis  may  develop  after 
puberty  as  the  first  open  outbreak  of  inherited  disease. 

Pathology. — The  cerebral  gumma  probably  always  has  its  origin  in  the 
membranes,  is  usually  surrounded  by  a  reddish  zone,  and  does  not  become  so 
uniformly  and  completely  caseous  as  the  tubercle,  from  which  it  is  further  dis- 
tinguished by  its  proneness  to  cause  cerebral  softening.  In  gummatous  men- 
ingitis the  exudation  forms  an  extended,  shapeless,  gelatinous  mass,  which  is 
in  the  majority  of  cases  situated  at  the  base  of  the  brain.  Microscopically,  the 
cerebral  gumma  differl  from  other  similar  bodies  only  in  the  presence  of  very 
large,  spider-like  cells  containing  an  exaggerated  nucleus  and  a  granular  proto- 
plasm, which  extends  into  the  multiple,  branching,  rigid  prolongations. 

Under  treatment  gummata  may  disappear  completely  or  may  leave  behind 
them  cicatrices,  imperfect  cysts,  or  even  calcareous  masses.  A  gumma  may 
involve  a  blood-vessel,  and,  extending  along  its  wall,  give  rise  to  a  thrombus 
with  secondary  softening.  A  gimimatous  inflammation  commencing  in  the 
pia  mater  may  infiltrate  a  wide  extent  of  the  cortex. 

Syphilitic  atheroma  of  the  cerebral  vessels  is  not  rare,  and  the  arteries  of 
the  base  are  especially  prone  to  suffer  from  a  peculiar  destructive  specific 
lesion  which  renders  them  whitish,  opaque,  and  hard,  and  finally  almost 
obliterates  their   lumen. 

Symptomatology. — Although  acute  or  fulminating  sypkilitic  coma  may 
devcloj)  abruptly  in  the  midst  of  apparent  health,  it  probably  is,  in  fact, 
always  preceded  by  headache,  vertigo,  or  other  prodrome.  The  coma  pro- 
duced by  the  obliteration  of  the  cerebral  vessels  is  usually  progressive,  the  true 
fulminating  coma  being  commonly  the  outcome  of  gummatous  inflammation. 
It  may  or  may  not  be  accompanied  by  delirium  or  convulsions.  A  patient  of 
my  own,  about  thirty  years  of  age,  became  very  drowsy  one  afternoon,  and  fell 

asleep.     In  a  few  minutes  sleep  changed  to  coma,  interrupted  an  hour  or  so 

72.; 


SYPHILITIC   DISEASE    OF    THE   B/iAIX.  I'll 

later  by  violent  delirium,  alternating  with  furions  eonvnlsions.  The  coma 
may,  however,  be  accompanied  with  comj)lete  muscular  relaxation  or  in  rare 
cases  by  local  or  hemiplegic  paralysis.  The  pulse-rate  may  fall  below  the 
norm  or  may  become  rapid  ;  the  arterial  tension  may  be  high  or  low,  and  the 
pulse- wave  large  or  small. 

It  is  of  vital  importance  to  recognize  that  the  symptoms  of  syphilitic  coma 
are  the  same  as  those  of  congestion  and  inflammation  of  the  brain  from  other 
causes,  and  that  the  first  treatment  in  a  serious  case  should  be  directed  not  so 
much  to  the  specific  disease  as  to  the  brain  congestion  which  it  has  provoked. 

The  symptoms  of  chronic  brain  syphilis  are  so  protean,  so  varying,  that  it 
is  almost  impossible  to  reduce  them  to  anv  order.  Possiblv,  the  most  dan- 
gerous  cases  are  those  in  which  the  symptoms  are  least  severe  and  so  elusive 
that  they  fail  to  cause  alarm.  Malaise,  a  little  brain  fiiilure,  a  succession  of 
causeless  headaches, — these  may  for  a  time  be  all  the  outcome.  After  a  greater 
or  less  continuance  of  thcoC  prodromes  epileptic  attacks  usually  develop,  with 
a  hemiplegia  or  a  monoplegia  which  is  almost  invariably  incom])lete  and  usually 
progressive;  very  frequently  diplopia  is  manifested  before  the  epilepsy,  and  on 
careful  examination  is  found  to  be  due  to  weakness  of  some  of  the  ocular 
muscles.  Not  rarely  oculomotor  palsy  is  an  early  and  pronounced  symptom, 
and  a  marked  paralytic  squint  is  very  common.  There  is  almost  always  dis- 
tinct failure  of  the  general  health  and  progressive  intellectual  deterioration,  as 
shown  by  loss  of  memory,  failure  of  the  power  to  fix  the  attention,  mental 
bewilderment,  morbid  somnolence,  perhaps  aphasia,  and  toward  the  end  of 
life  not  rarely  dementia.  If  the  case  convalesce,  the  amelioration  is  gradual, 
the  patient  travelling  slowly  up  the  road  he  has  come  down.  If  the  case  end 
fatally,  it  is  usually  by  a  gradual  sinking  into  complete  paralysis,  or  the  patient 
is  carried  off  by  an  acute  inflammatory  exacerbation,  or  a  very  violent  epileptic 
fit  may  produce  a  sudden  fatal  asphyxia.  Death  from  brain-softening  around 
the  tumor  is  not  infrequent,  but  a  fatal  apoplectic  haemorrhage  is  rare. 

It  is  almost  impossible  satisfactorily  to  reduce  to  any  order  or  types  the 
various  forms  of  cerebral  syphilis.  Besides  those  cases  which  resemble  demen- 
tia paralytica,  Henbner  makes  two  types:  (1)  psychical  disturbances,  with 
epilepsy,  incomplete  paralysis  (seldom  of  the  cranial  nerves),  and  a  final  coma- 
tose condition,  usually  of  short  duration  ;  and  (2)  genuine  apoplectic  attacks 
with  succeeding  hemiplegia,  in  connection  with  peculiar  somnolent  conditions 
occurring  in  oftcn-reix'ated  episodes;  frequently  phenomena  of  unilateral  irri- 
tation, and  generally  at  the  same  time  paralyses  of  the  cerebral  nerves. 

The  only  conformity  of  meningeal  syphilis,  as  I  have  seen  il,  witli  these 
tyjK-s  is  in  the  fact  that  when  e[)ik'psy  is  pronounced  the  basal  cranial  nerves 
arc  not  usually  paralyzed;  and  it  seems  necessary  to  adtl  Iwo  other  types  of 
disease — namely, 

(3)  Psychical  distinliance  witliout  complete  epilepfic  convulsions,  associatexl 
with  palsy  of  the  basal  nerves  and  often  wilh  j)ai'(ial  hemiplegia. 

(4)  Paraplegia  associated  wilh  ocular  ov  other  symptoms  indicative  of 
lesions  at  the  base  of  the  brain. 


728  SYPHILIS    OF    THE   NERVOUS   SYSTEM. 

Ill  nature,  however,  there  are  no  distinct  varieties  of  cerebral  syphilis,  all 
forms  cradino-  one  into  the  other,  and  it  is  most  satisfactory  to  study  the 
important  symptoms  separately. 

Headache  is  the  most  constant,  and  usually  the  earliest,  of  the  symptoms 
of  meningeal  syphilis,  but  it  may  be  entirely  wanting.  It  may  last  for  several 
years  without  the  development  of  other  distinct  symptoms,  and  sometimes  dis- 
appears when  these  appear.  It  has  no  fixed  character,  but  is  usually  paroxys- 
mal, and  may  occur  solely  in  the  form  of  very  distinct  and  very  violent  par- 
oxysms, accompanied  by  partial  unconsciousness  or  other  marked  congestive 
symptoms.  ])istinct  soreness  of  the  head  indicates  disease  of  the  skull  or  its 
periosteum. 

Insomnia  is  a  frequent  prodrome  of  cerebral  syphilis,  but  a  peculiar  somno- 
lence is  much  more  characteristic.  The  foudroyant  coma  has  already  been 
described  :  in  the  second  variety  of  syphilitic  stupor  the  symptoms  develop 
gradually.  The  patient  sits  all  day  long  or  lies  in  bed  in  a  state  of  semi-stupor, 
indifferent  to  everything,  but  capable  of  being  aroused,  answering  questions 
slowly,  imperfectly,  and  without  complaint,  but  in  an  instant  dropping  off  again 
into  his  quietude.  In  other  cases  the  sufferer  may  still  be  able  to  work,  but 
often  falls  asleep  while  at  his  tasks,  and  especially  toward  evening  has  an  irre- 
sistible desire  to  slumber,  which  leads  him  to  pass,  it  may  be,  half  of  his  time 
in  sleep.  This  state  of  partial  sleep  may  precede  that  of  the  more  continuous 
stupor  or  may  pass  oflP  when  an  attack  of  hemiplegia  seems  to  divert  the  symp- 
toms. TiiG  mental  phenomena  in  the  more  severe  cases  of  somnolency  are 
jieculiar.  Tiie  i)atient  can  be  aroused — indeed,  in  many  instances  he  exists  in 
a  state  of  torpor  rather  than  of  sleep  ;  when  stirred  up  he  thinks  with  extreme 
slowness,  and  may  appear  to  have  a  form  of  aphasia,  yet  at  intervals  he  may 
be  endowed  with  a  peculiar  automatic  activity,  especially  at  night.  Getting 
out  of  bed  ;  wandering  aimlessly  and  seemingly  without  knowledge  of  where 
he  is,  and  unable  to  find  his  own  bed ;  passing  his  excretions  in  a  corner  of  the 
room  or  in  some  other  similar  place,  not  because  he  is  unable  to  control  his 
bladder  and  bowels,  but  because  he  believes  that  he  is  in  a  proper  place  for  such 
acts, — he  seems  a  restless  nocturnal  automaton  rather  than  a  man.  Apathy  and 
indifference  are  the  characteristics  of  the  somnolent  state,  yet  the  patient  will 
sometimes  show  excessive  irritability  when  aroused,  and  will  at  other  periods 
complain  bitterly  of  pain  in  his  head,  or  will  groan  as  though  suffering  severely 
in  the  midst  of  his  stupor — at  a  time,  too,  when  he  is  not  able  to  recognize  the 
.seat  of  the  pain.  I  have  seen  a  man  with  a  vacant,  apathetic  face,  almost  com- 
plete aphasia,  persistent  heaviness  and  stupor,  arouse  himself  when  the  stir  in 
the  ward  told  him  that  the  attending  physician  was  present,  and  come  forward 
in  a  dazed,  highly  pathetic  manner,  by  signs  and  broken  utterances  begging  for 
something  to  relieve  his  head.  Heubner  speaks  of  cases  in  which  the  irrita- 
bility was  such  that  the  patient  fought  vigorously  when  aroused — this  I  have 
not  seen. 

After  some  days  of  excessive  somnolence  and  progressive  deepening  of  the 
ijtupor,  or  sometimes  more  rajjidly,  the  victim  of  cerebral  syphilis  may  pass 


SYPHILITIC   DISEASE    OF    THE   BRAIN,  729 

into  a  condition  of  profounfl  coma,  out  of  which  he  cannot  hv  aroused,  and 
during  which  his  fseees  and  urine  are  either  not  parsed  at  all  or  are  voided 
involuntarily.  This  condition  of  coma  may  end  in  death,  but  even  when  the 
symptom,  seem  most  serious  the  patient  may  gradually  recover,  slowlv  emerg- 
ing from  coma  into  stupor,  and  from  stupor  into  wakefulness  and  normal 
litK 

Motor  paralysis  is  very  frequent  in  cerebral  syjihilis.  It  sometimes  develops 
gradually,  but  it  may  appear  suddenly,  with  or  without  the  occurrence  of  an 
ajioplectic  or  epileptic  fit.  When  under  these  circumstances  the  paralysis  is, 
on  the  first  return  to  consciousness,  complete,  it  is  almost  alwavs  due  to  a  clot 
or  thrombus. 

The  characteristic  syphilitic  palsy  is  ]>rogressive  and  incom))lete.  Any  por- 
tion of  the  body  may  be  involved,  but  the  syphilitic  exudation  especially  haunts 
the  base  of  the  brain,  and  a  rapidly  but  not  abruptly  apjiearing  strabisnnis, 
ptosis,  dilated  pupil,  or  any  other  paralytic  eye-sym])tom  not  readily  accounted 
for  in  the  adult  is,  in  the  majority  of  cases,  syphilitic.  Tiie  specific  palsy  is 
often  temporary,  transient,  and  shifting.  Sensm'y  palsies  are  less  frequent  than 
motor  palsies,  but  hemianesthesia,  localized  anjesthesia,  indeed  any  form  of 
sensory  paralysis,  may  occur.  Special  sense-palsies  are  sometimes  present, 
whilst  specific  aphasia  is  common.  It  may  be  incomplete,  transitory,  and  par- 
oxysmal, but  is  more  apt  to  be  complete  and  to  have  permanency  than  are 
motor  paralyses.  Owing  to  the  tendency  of  syphilis  to  produce  multiple 
lesions,  a  lack  of  ap])arent  agreement  between  the  })alsy  and  the  aphasia  is 
almost  characteristic.  Thus,  Tanowsky  found  that  out  of  32  cases  of  syphilitic 
aphasia  with  hemiplegia,  in  14  the  paralysis  was  on  the  left  side.  Polyuria 
and  true  saccharine  diabetes  occur  in  cerebral  syphilis,  probably  as  the  result 
of  vaso-motor  disturbances. 

Epileptiform  comuilsions  are  a  most  characteristic  symptom.  A  history  of 
intense  and  protracted  headache,  followed  by  an  epileptic  fit,  in  an  adult  should 
excite  the  greatest  suspicion.  My  experience  is  in  accord  with  that  of  Four- 
nicr,  that  epileptiform  convulsions  not  due  to  alcoholism  or  unenn'a,  and  not 
appearing  until  after  thirty  years  of  age,  are  in  nine  cases  out  of  ten  specific. 
The  aura  is  rarely  present  ;  the  symptoms  may  \>v  unilateral  or  even  mono- 
])legic,  but  any  variety  of  epileptiform  convidsions  may  be  simulated.  Furious 
attacks  of  local  spasms  also  occur  without  loss  of  consciousness.  Then,  again, 
the  movements  may  be  continuous  and  distinctly  choreic. 

Psychical  Symptovis. — Apathy,  somnolence,  loss  of  memory,  and  general 
mental  failure  are  the  most  frequent  and  characteristic  mental  symptoms  of 
meningeal  syphilis;  but  almost  any  fijrni  of  insanity — mania,  niclaucholia, 
erotic  mania,  delirium  of  grandeur,  etc. — may  be  of  specific  origin.  TTsiially, 
sooner  or  later,  distinct  symj)toms  of  organic;  lesion  a|)p(  :ir.  i^spccially  common 
is  a  loss  of  mental  and  physical  power  similar  to  that  which  occurs  in  dementia 
paralytica. 

Diagnosis. — In  the  <liagnosis  of  cerebral  syphilis  loo  inucli  weight  should 
not  be  attached  to  the  history  of  tli<'  cax-,  as  non-syphililic,  organic  brain  dis- 


730  SYPHILIS    OF    THE   NERVOUS  SYSTEM. 

ease  may  occur  in  persons  who  have  had  syphilis,  and  cerebral  gumraata  may 
develop  in  persons  who  are  unconscious  of  ever  having  been  infected. 

The  prodromes  of  foudroyant  cerebral  syphilis  are  worthy  of  the  most  care- 
ful study  on  account  of  their  diagnostic  value  and  of  their  habitually  being 
overlooked  by  the  patients  themselves.  Persistent  headache,  slight  failure  of 
memory,  unwonted  slowness  of  speech,  general  lassitude,  and  lack  of  willing- 
ness to  mental  exertion,  sleeplessness  or  excessive  somnolence,  attacks  of 
momentary  giddiness,  vertiginous  feelings  when  straining  at  stool,  yelling  or 
in  any  way  disturbing  the  cerebral  circulation,  alteration  of  disposition, — any 
of  these  (and  a  fortiori  several  of  them)  occurring  in  a  syphilitic  subject 
should  be  the  immediate  signal  for  alarm.  Of  these  varied  possible  pro- 
dromic  symptoms  the  most  important  and  characteristic,  according  to  my 
experience,  are  headache  and  somnolence.  Slight  and  shifting  localized  weak- 
nesses sometimes  precede  an  acute  attack,  but  are  more  characteristic  of  the  dis- 
ease at  a  later  stage.  A  momentary  weakness  of  one  arm  ;  a  slight  drawing 
of  the  face,  disappearing  in  a  few  hours ;  a  temporary  dragging  of  the  toes ; 
a  partial  aj)hasia  which  appears  and  reappears ;  a  squint  which  to-morrow 
leaves  no  trace, — all  or  any  of  these  may  be  due  to  a  non-sy})hilitic  brain  tumor, 
to  miliary  cerebral  aneurisms,  or  to  some  other  non-specific  affection ;  but  in 
the  majority  of  cases,  when  tiiese  phenomena  occur  repeatedly  in  a  patient  who 
is  not  suffering  from  hysteria,  they  are  the  result  of  syphilis. 

In  a  doubtful  case  of  sudden  coma  other  ordinary  causes  must  be  elimi- 
nated :  a  pronounced  rise  of  temperature  or  a  pronounced  conjugate  deviation 
of  the  head  and  eyes  tells  strongly  against,  whilst  decided  ocular  palsy  or  a  par- 
tial paralysis  of  any  character  argues  in  favor  of,  a  specific  origin. 

Headache  occurring  with  palsy  or  with  a  history  of  attack  of  partial  mono- 
plegia or  hemiplegia,  vertigo,  pe^iV  mat,  epileptoid  convulsions,  disturbances  of 
consciousness,  attacks  of  unilateral  or  localized  spasms,  ocular  palsies,  epileptic 
forms  of  attacks  occurring  after  thirty  years  of  age,  morbid  somnolence, — any 
of  these,  even  when  existing  alone,  ought  to  be  sufficient  to  put  the  practitioner 
upon  his  guard.  Any  apparent  causelessness,  severity,  and  persistency  of  head- 
ache should  arouse  suspicion,  to  be  much  increased  by  a  tendency  to  nocturnal 
exacerbations  or  by  the  occurrence  of  mental  disturbance  or  of  giddiness  at  the 
crises  of  the  paroxysms.  Not  rarely  there  are  very  early  in  these  cases  curious, 
almost  indefinable,  disturbances  of  cerebral  functions  which  may  be  easily  over- 
lo(jked,  such  as  temporary  and  partial  failure  of  memory,  word-stumbling, 
fleeting  feelings  of  numbness  or  weakness,  and  alterations  of  disposition.  In 
the  absence  of  hysteria  any  indefinite  and  apparently  disconnected  series  of 
nerve-accidents  is  of  very  urgent  import.  To  use  the  words  of  Hughlings- 
Jackson  :  "  A  random  association  or  a  random  succession  of  nervous  symptoms 
is  very  strong  warrant  for  a  diagnosis  of  a  syphilitic  disease  of  the  nervous  sys- 
tem." Cerebral  syphilis  occurring  in  an  hysterical  subject  may  be  readily 
overlooked  until  fatal  mischief  is  done. 

The  age  of  the  patient  must  also  be  taken  into  consideration.  Apoplexy 
occurs   most  frequently   in   persons  over  fifty  years  of  age,  while  congestive 


SYPHILITIC   DISEASE    OE    THE   BRAIN.  731 

syphilitic  attacks  are  most  common  before  that  age.  The  course  of  a  case  for 
the  first  six  or  ten  hours  after  the  commencement  of  the  acute  paroxysm  is 
sufficiently  ditferent  in  the  two  affections  to  be  worthy  of  the  closest  study.  A 
hemiplegic  or  embolic  apoplexy  which  is  sufficiently  severe  to  keep  up  pro- 
nounced disturbance  of  consciousness  for  some  hours  is  almost  invariably 
accompanied  by  a  complete  hemiplegia,  or  more  rarely  by  some  other  form 
of  complete  palsy  ;  whilst  in  the  syphilitic  attack  the  paralysis  is  often  absent, 
and  probably  never  complete.  Unless  the  clot  has  been  a  very  large  one,  tiie 
return  to  consciousness  after  hemorrhagic  apoplexy  is  usually  much  more  rapid 
tlian  it  ordinarily  is  in  syphilitic  cases.  Headache  after  an  apoplexy  is  rare, 
whilst  headache  is  very  frequent  after  a  severe  sypliilitic  congestive  attack. 

The  peculiarities  in  the  symptoms  of  cerebral  syphilis  are  chieHy  due  to 
the  fact  that  the  lesions  are  apt  to  be  multiple  or  widespread  ;  to  be  rapidly 
developed  at  an  age  when  other  organic  diseases  are  rare ;  and  to  be  situated 
in  the  cerebral  cortex  or  at  the  base  of  the  brain.  Hence,  multiple  local  or 
partial  palsies  are  frequent,  whilst  the  symptoms  of  the  basal  chronic  menin- 
gitis in  the  non-tubercular  adult  are,  in  the  majority  of  cases,  the  outcome  of 
sy])hilis.  Homonymous  hemianopsia  is  very  rare,  because  the  occi})ital  lobes 
are  rarely  invaded.  Optic  neuritis  may  occur  in  specific  as  in  other  organic 
brain  diseases  :  it  usually  develops  with  moderate,  but  not  excessive,  rapiditv. 

The  diagnosis  of  cerebral  syphilis  during  life  is  always  a  matter  of 
inference.  When,  however,  the  symptoms  disappear  under  antisyphilitic 
treatment,  for  practical  purposes  the  diagnosis  may  be  considered  as  fixed. 
The  therapeutic  test  is  therefore  a  matter  of  the  gravest  importance.  The  old 
belief  of  syphilographers  that  tolerance  of  the  iodides  warrants  the  diagnosis 
of  syphilis  has  been  in  recent  times  strongly  combated,  but  I  still  thiid<  that, 
whilst  it  is  not  a  positive  sign,  the  tolerance  strongly  increases  the  probabilities 
of  specific  disease. 

Prognosis. — Although  death  may  occur  during  a  syphilitic  convulsion,  yet 
the  prognosis  of  an  acute  attack  of  cerebral  congestion  or  inflammation  due 
to  syphilis  is  on  the  whole  favorable,  although  it  should  be  somewhat  guarded. 
In  chronic  brain  syphilis  the  prognosis  is  favorable  for  more  or  less  complete 
recovery  unless  the  symptoms  indicate  an  absolute  destruction  of  brain  tissue. 
Whenever  amendment  of  the  symptoms  occurs  under  antispccific  medication, 
recovery  becomes  very  probable.  As,  however,  unexpe(;ted  accidents  occasion- 
ally happen,  it  is  best  not  to  make  the  prognosis  too  absolute. 

Treatment. — The  treatment  of  cerebral  syphilis  is  best  studied  under  two 
heads  :  first,  the  treatment  of  the  accidents  which  occur  in  \\\o  course  of  the 
disease;  second,  the  general  treatment  of  the  disease  itself 

In  the  accidents  of  cerebral  syphilis  the  treatment  should  be  that  which  is 
adapted  to  the  relief  of  the  same  symptoms  when  dejM'udent  upon  other  than 
specific  causes.  Thus,  in  fi>udroyant  c(jma,  iC  (licrc  be  pronounced  ni'terial 
excitement  or  if  the  patient's  strength  be  good,  venesection  should  be  resorted 
to  at  once.  T  have  seen  life  saved  by  the  abstraction  of  nearly  a  (piart  of 
blood,  whilst  in  other  cases  a  few  ounces  suflice.      Cure  nui>)  be  exercised  not 


732  SYPHILIS    OF   THE  XERVOUS  SYSTEM. 

to  mistake  a  simple  epileptiform  convulsion  for  a  pronounced  congestion  of  the 
brain,  but  if  there  be  epileptic  status  with  repeated  convulsions,  or  if  there  be 
violent  delirious  excitement,  venesection  may  be  resorted  to  if  the  patient's 
general  condition  permit.  In  severe  cases  the  bleeding  should  be  as  rapid  as 
possible,  and  be  continued  until  a  distinct  impression  is  made  upon  the  pulse. 
When  the  heart's  action  continues  violent  after  venesection,  the  hypodermic 
injection  of  the  tincture  of  aconite-root  (two  to  four  drops)  may  be  given 
every  half  hour  until  physiological  eifects  are  manifest.  In  feeble  cases  cup- 
ping to  the  back  of  the  neck,  stimulating  injections,  sinapisms  to  the  extrem- 
ities, cold  to  the  head,  croton  oil  as  a  derivative,  and  other  classical  remedial 
measures  for  brain  congestion  may  be  used. 

In  chronic  cerebral  syphilis  remedial  measures  looking  to  the  relief  of 
symptoms  may  occasioually  be  employed  with  teuiporary  advantage,  but  are 
of  comparatively  little  importance. 

The  first  therapeutic  question  to  be  decided  is  usually  as  to  the  choice 
between  mercurials  and  the  iodides.  Cerebral  gummata  may  develop  in  per- 
sons showing  marked  evidences  of  cachexia,  but  in  the  great  majority  of  cases 
cerebral  syphilis  aj^pears  at  a  time  when  there  is  no  general  breaking  down 
of  the  tissues  or  of  the  general  system.  The  choice  between  the  alternatives 
should  rest  upon  the  existing  symptoms,  and  not  upon  the  time  which  has 
elapsed  between  the  primary  infection  and  the  outbreak.  When  cachexia  con- 
traindicates  the  free  use  of  mercurials,  or  even  of  iodides,  tincture  of  iron  and 
corrosive  sublimate  may  be  given  together,  as  in  the  following  formula  : 

II.  Hydrarg.  chlor.  corrosiv.,  gr.  iss ; 

Tr.  ferri  chloridi,  fjij  ; 

Glycerinse,  f  ^j  ; 

Ol.  earyophylli,  Tllxviij  ; 

Syrupi,  q.  s.  ad  f^xviij. — M. 

Sig.  Teasj)oonful  in  water  after  meals. 

The  slowness  of  the  action  of  the  iodides  may  be  serious.  In  two  cases 
I  have  seen  death  occur  in  an  epileptic  fit  in  patients  who  were  rapidly 
improving  under  iodides.  If  mercury  had  been  exhibited  so  soon  as  these 
cases  came  under  care,  the  rapid  removal  of  the  lesions  would  have  probably 
prevented  the  fatal  fits.  More  and  more  has  it  become  with  me  a  favorite 
rule  of  action  in  cerebral  syphilis,  without  evidences  of  cachexia  or  a  history 
of  recent  mercurialization,  to  begin  the  treatment  with  mercury  in  such  doses 
as  are  necessary  to  cause  slight  salivation,  and  to  maintain  a  mercurial  impres- 
sion just  below  the  line  of  slight  tenderness  of  the  gums  for  some  days  or 
weeks,  pro  re  nata. 

The  method  of  administering  mercury  should  be  suited  to  the  exigencies 
of  the  individual  case.  If  mercurials  by  the  mouth  are  well  borne,  they 
should  be  so  administered.  If  the  symptoms  are  extremely  urgent,  the 
mercury  may  be  given  both  by  the  mouth  and  by  inunctions.     When  there 


SYPHILITIC  DISEASE    OF    THE   BRAIX.  733 

is  u  toiulencv  to  diarrhoea  the  mercurial  inunction  should  be  used  al()n(\  I  do 
nut  tiiink  that  the  oleate  is  preferable  to  the  old  blue  ointment :  a  half  drachm 
to  three  drachms  of  either  may  be  used  at  once.  An  excellent  plan  is  to  give 
a  hot  bath  late  in  the  afternoon  and  use  the  inunction  on  ffoino:  to  bed,  order- 
ing  the  patient  to  rub  the  ointment  on  Sunday  night  into  the  left  axilla; 
Monday  night,  into  the  left  flank ;  Tuesday  night,  into  the  inside  of  the 
left  thigh  ;  Wednesday  night,  into  the  right  axilla ;  Thui-sday  night,  into 
the  right  flank;  Friday  night,  into  the  right  thigh;  Saturday  night,  into  the 
region  of  the  umbilicus;  after  this  recommencing  with  the  left  axilla.  In 
Europe  the  mercury  is  often  given  hypodermically,  but  I  believe  that  the 
dangers  of  local  inflammation  overbalance  any  superiority  of  the  plan ; 
at  least  my  own  experience  of  hypodermic  injections  of  mercury  has  been 
siuijularlv  unfortunate. 

After  a  prolonged  mercurial  course  iodide  of  potassium  should  always  be 
given  in  order  to  secure  elimination  of  the  mercury  as  well  as  to  relieve  the 
syphilis.  The  dose  of  the  iodide  must  be  suited  to  the  individual  case.  It  is 
usually  best  to  begin  with  10  grains  three  times  a  day  ;  in  the  course  of  two 
or  three  days  this  may  be  increased  to  20  grains.  Usually  the  patient  who 
will  tolerate  a  drachm  of  iodide  a  day  will  also  tolerate  two  drachms  a  day. 
A  majority  of"  those  persons  mIio  can  take  two  drachms  a  day  without  the 
production  of  iodism  can  take  three  drachms.  It  is  therefore  safe  to  advance 
the  dose  very  ra]>idly  after  it  has  been  found  that  a  drachm  a  day  causes  no 
inconvenience.  Not  rarely  it  seems  almost  impossible  to  produce  iodism. 
I  have  frequently  given  the  iodides  up  to  or  even  beyond  six  drachms  a  day. 

1  do  not  believe  that  larger  amounts  than  these  are  of  any  especial  service, 
and  I  am  not  sure  that  any  advantage  is  gained  by  going  beyond  a  daily 
dose  of  half  an  oimee. 

The  iodide  is  so  soluble  that  a  watery  solution,  one  minim  of  which  rep- 
resents a  grain  of  the  salt,  is  readily  made  and  is  permanent.  I  have  been 
accustomed  to  use  the  following  formula,  directing  the  patient  to  add  to  a 
dessert-  or  tablespoonftd  of  No.  2  and  a  quarter  tumbler  of  water  the  desired 
number  of  minims  of  No.  1  : 

I^.  Potassii  iodidi,  5J  ;  ^-  Syr.  sarsap.  comp.,         f.^vj. 

Aquae,  f.sj.  S.  No.  2. 

M.  et  ft.  sol.  S.  No.  1. 

I  am  not  sure  that  the  abandonment  by  the  ]»rofession  of  the  use  of  the 
so-called  "Woods"  is  right.  I  have  seen  "Zitmann's  decocticm"  do  good 
after  the  failure  of  the  other  forms  of  the  iodides  and  mercurials.  A  fair 
imitiition  of  the  old  "  Woods"  may  be  obtained  by  sui)stituting  for  Number 

2  of  the  fornnda  just  given  a  nuxture  of  e<(ii;d  j.arls  of  (he  compound  fluid 
extract  and  compound  syrup  of  sarsa[>:iiilla. 


734  SYPHILIS    OF    THE   NERVOUS  SYSTEM 

Spinal    Syphilis. 

The  pathology  of  the  acute,  explosive  form  of  spinal  syphilis,  in  which 
the  symptoms  resemble  those  of  Landry's  paralysis,  is  at  present  uncertain. 
It  is  not  known  whether  the  disease  is  centric  or  is  a  peripheral  neuritis. 

The  second  form  of  spinal  syphilis  is  that  in  which  softening  of  the  cord 
occurs  as  the  result  of  previous  syphilitic  disease  of  the  blood-vessels.  The 
third  form  is  that  in  which  syphilitic  neoplasms  develo]>.  The  fourth  variety 
is  that  in  which  a  gummatous  infiltration  occurs,  commencing  in  the  pia  mater 
and  spreading  inward,  involving  the  cord  even  into  the  gi-ay  matter,  the  first 
change  being  usually,  if  not  always,  thickening  of  the  walls  of  the  blood- 
vessels, with  dilatation  of  the  perivascular  spaces  and  exudation  of  minute 
cells  around  the  vessels.  Heubner  describes  another  variety  of  spinal  syphilis 
in  which  there  is  found  after  death  a  condensation  of  the  cellular  tissues 
around  the  cord.  This  so-called  sypJiiUtic  callus  is  probably  not  a  primary 
syphilitic  lesion,  but  the  resultant  of  true  gummatous  inflammation. 

Symptomatology. — Spinal  softening  and  spinal  neoplasms  due  to  syphilis 
produce  .symptoms  similar  to  those  caused  by  similar  lesions  not  due  to  syphilis. 
The  symptoms  of  gummatous  spinal  meningitis  are  those  of  a  localized  sub- 
acute meningitis — namely,  pain  and  spasm,  with  paralysis,  aifec;ting  some 
peripheral  part  corresponding  to  the  seat  of  the  lesion.  The  pains  are  some- 
times exceedingly  severe,  furious  agonies  shooting  along  the  afi^ected  nerves  or 
fulgurant  crises  simulating  those  of  true  locomotor  ataxia.  Often  there  is 
acliing  in  the  back.  When  this  aching  is  accompanied  by  marked  soreness 
on  pressure  or  on  jarring,  the  vertebrae  themselves  may  be  considered  to  be 
aifected.  Various  parsesthesise,  marked  hypersesthesia  or  anaesthesia,  girdle 
pains,  tonic  spasms,  localized  tremors,  grossly  exaggerated  reflexes, — such  are 
the  symptoms  of  irritation,  which  may  be  followed  by  complete  paralysis  with 
trophic  changes. 

The  symptoms  of  diffused  syj>hilitic  infiltration  of  the  cord  vary  with  the 
seat  of  the  lesion,  simulating  now  locomotor  ataxia,  now  spastic  paraplegia, 
now  chronic  mycliti.s. 

Diagnosis. — The  recognition  of  the  true  nature  of  the  spinal  syphilis  must 
dejiend  upon  the  study  of  the  collocation  of  the  symptoms  rather  than  of  the 
individual  .symptoms  themselves. 

The  lesions  of  syphilis  are  prone  to  be  multiple,  and  are  rarely  as  strictly 
confined  to  individual  functional  tracts  as  in  sclerosis;  consequently,  the 
symptoms  of  .syphilis  of  the  cord  are  very  apt  to  be  mixed.  Thus,  there  will 
be  loss  of  co-ordination  associated  with  retention  of  the  patellar  reflex  ;  or  the 
]xitellar  reflex  may  be  lost  at  a  time  when  there  is  marked  loss  of  power  in  the 
muscles  rather  than  loss  of  their  co-ordinating  function  ;  or  an  apparent  loco- 
motor ataxia  will  1)e  associated  with  loss  of  power  over  the  rectum  or  bladder; 
or  a  case  which  up  to  a  certain  point  offers  a  typical  ontline  of  lateral  sclerosis 
suffers  from  fulgurant  pains  or  from  paralysis  of  the  sphincters. 

Almost  any  conceivable  mixture  or  interweaving  of  spinal  symptoms  may 


SYPHILIS    OF   THE   PEBIPHEBAL    NERVES.  735 

occur  as  the  result  of  syphilis  of  the  cord,  so  that  the  most  pathognomonic 
evidence  of  the  existence  of  the  disease  is  an  atypical  aggregation  of  symptoms. 
Whenever  a  contradictory  mass  of  phenomena,  evidently  spinal  in  orio;in,  pre- 
sent themselves  before  the  practitioner,  suspicion  should  at  once  be  stronglv 
aroused. 

Prognosis. — The  prognosis  in  spinal  syphilis  is  less  favorable  than  in 
syphilis  of  the  brain.  Frequently  great  improvement  can  be  obtained  by 
treatment,  and  alleged  cures  are  not  rare;  but  even  in  these  so-called 
''cures"  careful  examination  will  usually  reveal  the  existence  of  some  perma- 
nent damage. 

Treatment. — In  the  treatment  of  spinal  syphilis  the  most  urgent  haste 
should  be  made  by  the  free  use  of  the  mercurials  to  break  down  the  gum- 
matous exudation  before  it  shall  have  produced  secondary  degeneration  in  the 
spinal  cord.  Only  the  most  distinct  cadiexia  justifies  the  beginning  of  the 
treatment  with  iodides.  Absolute  or  partial  rest  should  always  be  enforced 
during  the  treatment,  whilst  the  hot  and  cold  douche,  massage,  muscle-beaters, 
faradization,  and  other  remedial  measures  and  appliances  may  be  used  to  keep 
up  the  circulation  and  nutrition  of  the  affected  muscles.  These  palliative 
measures  are,  however,  of  very  little  im[)ortance  as  contrasted  with  tire  anti- 
specific  medication.  When  the  vertebrae  are  involved,  immediate  treatment 
by  suspension  should  be  resorted  to,  and  the  plaster  jacket  or  one  of  its  sub- 
stitutes should  be  used. 

Syphilis  of  the  Peripheral  Nerves. 

Syphilitic  Affections  of  the  peripheral  nerves  are  rare,  but  occur  in  three 
forms:  first,  pressure  neimtis,  including  those  cases  in  which  the  nerve-trunk 
is  affected  simply  by  pressure,  the  alterations  not  being  in  any  jiroper  sense 
specific;  second,  secondary  syphilitic  infiltration,  including  those  cases  in  which 
the  nerve-trunk  is  involved  in  a  syphilitic  deposit  which  has  commenced  in  a 
neighboring  organ  and  has  secondarily  infiltrated  the  nerve  with  gummatous 
tissue;  third,  primary  nei've-si/philis,  including  those  cases  in  which  the  lesion 
is  distinctly  specific  and  primary.  Of  these  varieties  of  nerve-syphilis,  only 
the  last  seems  to  need  any  pathological  discussion  here. 

I  have  occasionally  noted,  in  cases  in  which  there  was  evident  specific  dis- 
ease of  the  nerve-centres,  a  coincident  tenderness  of  nerve-trunks,  indicating 
that  the  latter  were  in  a  condition  of  inflammation,  but  have  always  been  very 
doubtful  as  to  whether  such  neuritis  should  be  considered  as  due  directly  to  the 
specific  poison,  or  whether  it  were  not  simply  a  secondary  inflammation  prop- 
aerated  alon<'-  the  nerve-trunk  irritated  bv  a  ginnma  somewhere  in  its  course. 
A  case  published  in  the  Wien.  vied.  Blatter  for  188G  by  Dr.  S.  Erhmann 
makes  it  probable,  however,  that  the  sy])liiliti(;  poison  may  act  like  the  rheu- 
matic, the  alcoholic,  the  plumbic,  an<l  kindred  poisons  in  producing  wide- 
spread polyneuritis.  Further  observalions  seem,  however,  necessary  before  this 
conclusion  can  Ix;  considered  as  established. 

Primary  gummatous  syphilis  of  thcwe  pitrtions  of  the  peripheral  nerves 


736  SYPHILIl^    OF    THE   NERVOUS  SYSTEM. 

whicJi  lie  outside  of  the  bony  cavities  is  extremely  rare  ;  the  nerve-roots  or 
trunks  inside  of  the  vertebrae  and  cranium  are  more  frequently  attacked ; 
usually,  however,  in  these  cases  neighboring  larger  gummata  exist  in  the 
nerve-centres  or  in  the   membranes. 

The  first  change  is  an  infiltration  of  the  wall  of  the  blood-vessels  in  the 
nerves  with  minute  cells.  As  the  process  continues  the  vessels  become  more 
and  more  enlarged  and  tortuous,  and  the  infiltration  forces  itself  a  way  through 
the  trabeculse  of  the  nerve,  whilst  the  nerve-bundles  themselves  gradually  dis- 
appear, and  often  can  be  seen  in  various  parts  of  the  preparation  undergoing 
degeneration.  When  the  process  is  complete  the  blood-vessels  themselves  have 
been  destroyed,  and  the  position  of  the  obliterated  arteries  may  be  seen,  in  the 
syphilitic  product,  occupied  by  spindle-form  cells  and  the  evidences  of  fibroid 
structure.  Tiie  epineurium,  or  sheath  of  the  nerve,  is  usually  distended  or 
spread  out  over  the  growth,  but  very  rarely  is  it  completely  destroyed. 

The  symptoms  which  are  produced  by  nerve-gum  ma  are  almost  always 
intermingled  with  those  which  are  due  to  implication  of  the  nerve-centres, 
since  it  is  extremely  rare  for  nerve-gumma  to  exist  as  an  early  single  lesion. 
Pain,  spasm,  and  even  paralysis  are  not  infrequently  the  outcome  of  disease 
of  the  spinal  nerve-roots,  but  it  is  very  unusual  for  the  disease  of  the  nerve- 
roots  to  go  so  far  as  to  entirely  abolish  their  functions.  Thus,  pain  of  a 
most  atrocious  character  following  the  distribution  of  their  nerve-trunks  is 
much  more  frequently  seen  than  is  anaesthesia,  and  very  infrequently  does  a 
motor  nerve  suffer  sufficiently  for  the  production  of  distinct  trophic  changes 
in  its  tributary  muscles.  In  my  own  experience  the  trigeminus  nerve  has 
been  more  frequently  attacked  than  any  other.  I  have  seen  the  most  atrocious 
tic  douloui-eux  as  the  sole  symptom  of  a  gummatous  syphilis  situated  within 
the  cranium. 

The  treatment  of  this  form  of  nervous  syphilis  should  be  actively  anti- 
syphilitic. 


ORGANIC  DISEASES  OF  THE  SPINAL  CORD 
AND  ITS  MEMBRANES. 

By  HORATIO  C.  WOOD. 


Spinal  Localization. 

When  the  practice  of  medicine  has  to  be  discussed  within  limits  so  narrow 
as  those  of  the  present  vohmies,  detailed  anatomical  considerations  are  out 
of  i)lace :  the  student  should  be  already  furnished  with  anatomical  and  physi- 
ological knowledge.  Nevertheless,  for  the  purposes  of  review  it  does  seem 
proper  here  briefly  to  point  out  by  text  and  diagrams  those  anatomical  and 
physiological  facts  concerning  the  spinal  cord  which  have  special  relations  to 
the  localization  of  disease. 

Localization  of  spinal  disease  is  twofold:  it  relates  disease,  in  the  first  place, 
to  the  anatomico-physiological  tracts  of  the  spinal  cord  ;  in  the  second  place, 
to  the  vertical  position  of  the  lesion  in  the  cord.  The  white  matter  of  the 
spinal  cord  is  divided  into  certain  so-called  longitudinal  tracts  or  columns, 
which  are  set  forth  in  the  accompanying  diagram. 

Fig.  49. 
ANT.  ROOT 


Q\•;;•;o^>>;;i55i•'^:;:^^:•^:•■"^      " 


Diagranitnatic  Scclioii  vi  Spinal  Cord. 

The  Posterior  Median  Column,  <>r  the  Colunm  (.((Ji.ll,  lies  iminediatcly  in 
contact  with  the  po.sterior  fissure  of  the  cord,  it  is  ((HiiiMiscd  chiefly  nC  fibres 
which  enter  through  the  posterior  nerve-roots  and  i)ass  upward.  Tlic  increase 
in  the  size  of  the  column  of  (loll  from  below  upward  <locs  not  scetu  to  be  suf- 
ficient for  the  accommodation  oC  all  of  llie  fibres  tliat   culcr  llic  column,  sup- 

Voi,.  I.— »7  7;i7 


738 


ORGANIC   DISEASES    OF    THE  SPINAL    CORD. 


posing  that  these  fibres  continuously  travel  upward  to  the  brain  ;  further,  the 
function  of  the  column  of  Goll  still  remains  in  doubt;  it  is  indeed  probable 
that  some  or  possibly  all  of  the  fibres  escape  from  the  column  before  reaching 
its  summit,  but  how  or  where  such  escape  is  made  still  remains  uncertain. 

Next  to  the  column  of  Goll  lies  the  Postero-external  Column,  the  Column 
of  Burdach,  or  the  Posterior  Root-zone,  chiefly  composed  of  vertical  fibres, 
whose  function  is  at  present  unknown. 

The  Direct  Cerebellar  Tract  seems  to  be  chiefly  composed  of  fibres  which 
enter  it  through  the  lateral  column  from  the  gray  substance  and  pass  upward. 
It  seems  to  have  the  function  of  conducting  impulses  upward,  and,  according 
to  Flechsig,  it  probably  carries  impressions  from  the  trunkal  muscles. 

Both  the  lateral  pyramidal  tract,  "  crossed  cerebral  tract,"  and  the  anterior 
pyramidal  tract,  *'  direct  cerebral  tract,"  or  column  of  Turck,  are  composed  of 
fibres  whose  course  is  downward  from  the  pyramids  of  the  medulla.  At  the 
decussation  of  the  pyramids  about  three-quarters  of  the  fibres  cross  over  to 
form  the  lateral  tract,  whilst  the  remaining  fourth  of  the  fibres  enter  the  cord 
without  decussation  and  constitute  the  anterior  tract.  The  fibres  of  both  pyr- 
amidal tracts  finally  pass  through  the  gray  matter  of  the  spinal  cord  into  the 


Fig.  50. 


Uppei  Dordal  1st   Lumbar.  Mid-Lumbar. 

Diagrams  of  the  Groups  of  Nerve-cells  in  the  .interior  Cornu:  Group  I.,  inner  or  medial;  A,  anterior; 
A.Ia,  antero-lateral:  P.L.,  posterolateral :  I.L.P.,  intermediate  lateral  process  ;  P.V.C,  posterior  vesic- 
ular column  or  tract.  Tlie  two  mid-cervical  sections  are  only  a  few  millimetres  apart,  and  show  how 
the  anterior  group,  separate  in  the  one,  may  be  blended  with  the  antero-lateral  group  in  a  neighboring 
part  of  the  cord  (Gowers). 


anterior  cornua,  and,  although  they  have  not  been  traced,  almost  certainly  end 
in  the  processes  of  the  motor  cells.  Their  function  is  to  conduct  from  above 
downward,  and  they  probably  are  the  pathway  by  which  impulses  from  the 
motor  regions  of  the  cerebral  cortex  reach  the  motor  ganglionic  cells  of  the 
spinal  cord,  who.se  answering  discharges  provoke  the  final  muscular  contraction. 
The  remaining  portion  of  the  white  matter  of  the  spinal  cord  is  composed, 


.4 


SPINAL    LOCALIZATION.  789 

first,  of  the  so-called  Antero-lateral  Ascending  Tract  (A.  L.  A.  T.),  which 
forms  the  periphery  of  the  anterior  portion  of  the  cord  ;  second,  the  mass  of 
white  fibres  marked  in  the  diagram  as  the  anterior  ground-fibres.  The  func- 
tion of  these  portions  of  the  spinal  cord  have  not  been  made  out.  Flechsig 
also  anatomically  separates  the  little  patch  of  white  matter  between  the  lateral 
pyramidal  tract  and  the  gray  matter,  marked  in  the  diagram  L.L.L.,  and 
known  as  the  lateral  limiting  layer.  The  separation  of  the  antero-lateral 
tract  from  the  so-called  anterior  ground-fibres  does  not  seem  to  me  at  present 
warranted,  either  on  anatomical  or  physiological  grounds.  Indeed,  it  is 
doubtful  whether  there  is  sufficient  continuity,  either  of 
structure  or  of  function,  for  any  of  the  parts  of  the  spinal  '°' '   ' 

cord  spoken  of  in  this  paragraph  to  be  considered  as  dis-  <;:*w#'fr;    -  ic 

tinct  columns  or  tracts;  and  I  doubt  whether  any  degen-  ^^'IS > 

eration  ever  follows  the  course  of  these  reofions.  3  ^"^If^ ' 

The  gray  matter  of  the  spinal  cord,  besides  the  numerous  *  ^'15 ' 

conducting  fibres  which  it  contains,  has  situated  in  it  gan-  '  ^°'M} 

glionic  cells  whose  processes  are  prolonged  into  nerve-fibres  ° \^'j       '° 

composed  solely  of  the  axis-cylinders.    The  ganglionic  cells         3  ^j;^ 

are  arranged  in  groups  which  vary  in  different  portions  of 

the  cord,  and  probably  in  the  same  portion  of  the  cord  in        *  7A^\ 

different  individuals.     The  most  readily  recog-nized  of  the  mW^ ' 

groups  are  the  small   inner  or  medial  group,  situated  in        g  (/liotfTi  ' 

the  inner  anterior  angle  of  the  cornua  ;  the  large  anterior        «  (/\ 
group,  placed  near  the  anterior  edge  of  the  cornua,  in  the        '° 

middle  or  a  little  to  the  outer  side  of  the  middle  of  the       «  ^Ir " 

margin  ;  the  anterior  lateral  group,  situated  in  the  outer       >•'  ^^JIt "" 

extremity  of  the  front  of  the  cornua  (the  last  two  groups         *  bCn,.  ^ 
frequently    consolidate) ;    the    external    or    postero-lateral        ^  ( jlirr 
group,   which   is   usually  the  largest  and  is  extended    in        s  o-^zm^. 

the  posterior  outer  angle  of  the  cord.     The  diagram  (Fig.      s  Cml^^ -  -'s 

50),  taken  from  Gowers,  shows  the  general  arrangement 
of  these  groups  in  four  different  portions  of  the  cord. 

The  most  condensed  statement  of  the  facts  necessarv  fi)r       <C - — ^ 

.  .  •  Coll Co- 

the  ])ractitioner  to  know  for  the  purpose  of  locating  ver- 
tical lesions  of  the  spinal  cord  that  I  am  acquainted  with,  Amiiomy  <.f  the  spiimi 
IS  contained  in  tlie  table  of  rroicssor  m..  Allan  Starr.  c,  (xTvicai;  d.  ti.irsai; 
Bv  means  of  this    table   and    the  diagram   of   l*rofessor  '-  '"•"i^"'-;  s,  .sacrui; 

•  _  "  Co,  coccyx. 

Gowers  (Fig.  51),  both  of  whicli  are  here  rej)roduced,  the 
vertical  position  of  almost  any  spinal  lesion  can  be  determined.  In  studying 
the  diagram  and  tabic  it  must  be  remembered  that  the  cervical  cord  is  divided 
into  eierht  se<rments,  and  that  ''TI.  and  III.  C\"  in  tlie  first  eoluimi  of  the 
table  refer  to  second  and  tiiird  cervical  segment'^;  lliat  (lie  ddisal  cord  is 
<livided  into  twelve  segments,  "  I.  I),,"  an<l  so  on  ;  tiiat  (he  lumbar  cord  is 
<iivided  into  five  segments,  and  the  sacral  al.'-Jo  into  five  segments  ;  thus,  '*  III. 
to  V.  S."  means  third  (o  fifth  sacral  segments. 


740 


ORGANIC  DISEASES    OE    THE   SPINAL    CORD. 


Segment. 


II.  and  III.  C. 


IV.  C. 


Muscles. 


V.  C. 


VI.  C. 


VII.  C. 


VIII.  C. 

I.  D. 

II.  to  XII.  D. 


I.  L. 


II.  L. 


III.  L. 


IV.  L. 


V.  L. 


I.  to  II.  S. 


III.  to  V.  S. 


Sterno-mastoid. 
Trapezius. 
Scaleni  and  neck. 
Diaphragm. 

Diaphragm. 
Deltoid. 

Biceps. 

Coracobiachialis. 

Supinator  longus. 

Rhomboid. 

Supra-  and  infraspinatus. 

Deltoid. 

Biceps. 

Coi  aco-brachialis. 

Brachialis  anticus. 

Supinator  longus. 

Supinator  brevis. 

Rhomboid. 

Teres  minor. 

Pectoralis  (clavicular  part). 

Serratus  magnus. 

Biceps. 

Brachialis  anticus. 

Pectoralis  (clavicular  part). 

Serratus  magnus. 

Triceps. 

Extensorsofwristand  fingers. 

Pronators. 

Triceps  (long  head). 

E.x tensors  of  wrist  and  fingers. 

Pronators  of  vifrist. 

Flexors  of  wrist. 

Subscapular. 

Pectoralis  (costal  part). 

Latissimus  dorsi. 

Teres  major. 

Flexors  of  wrist  and  fingers. 
Intrinsic  muscles  of  hand. 

Extensors  of  thumb. 
Intrinsic  hand-muscles. 
Thenar  and  hypothenar  emi- 
nences. 

Muscles    of    back    and     ab- 
domen. 
Erectores  spinse. 


Ilio-psoas. 
Sartorius. 
Muscles  of  abdomen. 

Ilio-psoas. 

Sartorius. 

Flexors  of  knee  (Remak). 

Quadricei)S  femoris. 

Quadriceps  femoris. 
Inner  rotators  of  thigh. 
Abductors  of  thigh. 

Abductors  of  thigh. 
Abductors  of  thigh. 
Flexors  of  knee  (Ferrier). 
Tibialis  anticus. 

Outward  rotators  of  thigh. 
Flexors  of  knee  (Ferrier). 
Flexors  of  ankle. 
Extensors  of  toes. 

Flexors  of  ankle. 

Long  flexor  of  toes. 

Peronci. 

Intrin.sic  muscles  of  foot. 

Perineal  muscles. 


Reflex. 


Hypochondrium  (?). 

Sudden   inspiration    produced    by 

sudden     pressure    beneath    the 

lower  border  of  ribs. 

Pupil.  Fourth  to  seventh  cervical. 
Dilatation   of  the  pupil  produced 
by  irritation  of  neck. 


Scapular. 

Fifth  cervical  to  first  dorsal. 

Irritation  of  skin  over  the  scapula 
produces  contraction  of  the  scap- 
ular muscles. 

Supinator  longus. 

Tapping  its  tendon  in  wrist  pro- 
duces flexion  of  forearm. 


Triceps. 

Fifth  to  sixth  cervical. 

Tapping   elbow  tendon    produces 

extension  of  forearm. 
Posterior  wrist. 
Sixth  to  eighth  cervical. 
Tapping  tendons  causes  extension 

of  hand. 

Anterior  wrist,. 

Seventh  to  eighth  cervical. 

Tapping  anterior   tendons  causes 

flexion  of  wrist. 
Palmar ;  seventh  cervical  to  first 

dorsal. 
Stroking  palm  causes   closure  of 
fingers. 


Epigastric,  fourth  to  seventh  dor- 
sal. 

Tickling  mammary  region  causes 
retraction  of  the  epigastrium. 

Abdominal,  seventh  to  eleventh 
dorsal. 

Stroking  side  of  abdomen  causes 
retraction  of  belly. 

Cremasteric,  first  to  third  lumbar. 

Stroking  inner  thigh  causes  retrac- 
tion of  scrotum. 

Patella  tendon. 

Striking  tendon  causes  extension 
of  leg. 


Gluteal. 

Fourth  to  fifth  lumbar. 
Stroking  buttock  causes  dimpling 
in  fold  of  buttock. 


Plantar. 

Tickling  sole  of  foot  causes  flexion 
of  toes  and  retraction  of  leg. 

Foot  reflex. 

Achilles  tendon. 

Over-extension  of  foot  causes  r&pid 

flexion;  ankle  clonus. 
Bladder  and  rectal  centres. 


Sensation. 


Back  of  head  to  vert«x. 
Neck. 


Neck. 

Upper  shoulder. 

Outer  arm. 


Back  of  shoulder  and  arm. 
(Juter  side  of  arm  and  fore- 
arm, front  and  back. 


Outer  side  of  forearm,  front 

and  back. 
Outer  half  of  hand. 


Inner  side  and  back  of  arm 

and  forearm. 
Radial  half  of  the  hand. 


Forearm  and  hand,  inner  half. 

Forearm,  inner  half. 
Ulnar  distribution  to  hand. 


Skin  of  chest  and  abdomen, 
in  bands  running  around 
and  down  ward,  correspond- 
ing to  .spinal  nerves. 

Upper  gluteal  region. 


Skin  over  groin  and  front  of 
scrotum. 


Outer  side  of  thigh. 


Front  and  in  ner  side  of  thigh. 


Inner  side  of  thigh  and  leg 

to  ankle. 
Inner  side  of  foot. 

Back  of  thigh,  back  of  leg, 
and  outer  part  of  foot. 


Rack  of  thigh. 

Leg  and  foot,  outer  side. 


Skin  over  sacrum. 

Anus. 
Perineum. 

Genitals. 


f 


hjematorrhacitts.—acvte  spinal  MEXIXGITIS.     741 

H^MATORRHACHIS    (HEMORRHAGE    INTO    THE    SpINAL    MeMBRANES). 

Etiolog-y.— By  the  bursting  of  aneurisms,  tearing  of  spinal  arteries  by 
violence,  etc.  the  spinal  cord  and  its  membranes  may  be  involved  in  extra- 
ordinary outpourings  of  blood  ;  whilst,  on  the  other  hand,  minute  htemorrhages 
into  the  spinal  membranes  often  occur  as  complications  of  various  constitu- 
tional or  local  disorders  and  give  no  sign  of  their  presence.  Moderate 
htematorrachis  may  be  produced  by  injury  or  acute  blood  disease;  but,  in 
the  cases  that  I  have  seen,  it  has  been  the  outcome  of  svohilitic  deo-eneration 
of  the  blood-vessels. 

In  hffimatorrhachis  the  dominant  symptom  is  an  acute  paralysis  which 
takes  the  form  of  a  paraplegia,  abrupt  and  extremely  rapid  in  its  course, 
but  still  requiring  some  minutes  or  hours  for  its  completion,  during  which 
time  there  is  great  pain  in  the  back  and  extremities.  The  rate  of  the 
development  of  the  paralysis  varies  according  to  the  amount  and  rapidity  of 
the  haemorrhage.  The  loss  of  ])ower  is  due,  not  to  an  immediate  lesion  of  the 
cord,  but  to  the  pressure  of  the  exuded  blood  upon  the  cord,  and  especially 
upon  the  motor  nerve-roots.  Unless  the  blood  be  in  great  amount  and  thrown 
out  with  excessive  rapidity,  the  paralysis  grows  more  and  more  marked  during 
several  hours,  and  at  the  same  time  ascends  higher  and  higher.  As  the  blood 
creeps  up  the  spinal  cord  or  forces  its  way  downward  it  tears  the  membranes 
away  from  the  cord,  presses,  stretches,  or  perhaps  tears  the  posterior  as  well 
as  the  anterior  nerve-roots,  and  produces  thereby  muscular  contractions  and 
spasms  with  loss  of  muscular  power,  as  well  as  shooting,  tearing,  or  burning 
pains  with  more  or  less  marked  loss  of  sensibility.  The  amesthesia  is  usually 
not  as  complete  or  as  abrupt  as  in  cases  of  intraspinal  apoplexy.  Neverthe- 
less, if  the  clot  be  a  large  one  the  sensory  palsy  may  be  complete,  and  the  zone 
between  the  anaesthetic  and  the  sensitive  portions  may  be  very  narrow.  (Con- 
sciousness and  intellection  are  not  affected  except  in  rare  cases,  and  then  only 
in  the  first  moments  of  attack.  The  bladder  and  rectum  are  very  commonly 
paralyzed.  Priapism  or  other  evidences  of  genito-urinary  irritation  might 
naturally  be  expected,  but  I  have  never  seen  them. 

The  prog-nosis  of  hsematorrhachis  is  very  serious,  most  of  the  cases  ending 
fatally.  There  is  no  specific  treatment:  in  a  robust  subject,  seen  early,  free 
venesection  would  be  justifiable. 

Acute  Spinal  Meningitis. 

Definition. — An  acute  inflaininatioii  of  thcsj)inal  membranes,  not  syphilitic. 

It  is  usual  to  divide  acute  inflammation  of  the  spinal  membranes  into  acute 
spinal  pf(ehyme7irnf/ilif<,  or  inflammation  of  the  dura  mater,  and  acute  Iqdo- 
mniirir/ifis,  or  inflammation  of  (he  arachnoid  or  pia  inatci-.  ( 'oimnonly,  how- 
ever, all  of  {\\c  iii(iiil)ranes  are  affected,  and,  except  as  the  rcsiih  of  injury  or 
of  septic  poisoning,  it  seems  doubtful  whether  acute  spinal  jiacliymeningitis 
exists;  and  even  tin;  septic;  ninl  trainimtic  forms  ol"  (he  disease  are  almost 
always  associated  with   inflanjmatioM  of  the  other  nieiubraries.     'j'lie  diagnosis 


742  ORGANIC  DISEASES    OF    THE  SPINAL    CORD. 

of  acute  pachymeningitis  is  said  to  rest  upon  pain  in  the  back,  increased  by 
movements  of  the  trunk  ;  cutaneous  hypersesthesia ;  tingling,  or  numbness  in 
various  parts  of  the  surface  of  the  body ;  paresis  or  paralysis  of  the  lower 
extremities  in  severe  cases  ;  along  with  a  history  of  vertebral  disease  or  injury 
or  of  suppurative  disease  in  the  neighborhood  of  the  spine. 

Etiology. — Acute  spinal  meningitis,  not  dependent  upon  blood-poisoning, 
is  an  exceedingly  rare  disease,  but  is  said  to  be  occasionally  produced  by 
severe  exposure  to  heat  or  cold.  It  occurs  most  frequently  in  young  persons 
of  the  male  sex. 

Symptomatolog-y. — Acute  spinal  meningitis  usually  commences  with  a 
distinct  rigor,  followed  by  high  fever,  arterial  excitement,  and  other  constitu- 
tional evidences  of  an  active  inflammation.  At  the  same  time,  severe  pain, 
affecting  the  whole  extent  of  the  spine,  comes  on,  rapidly  becomes  very  severe, 
and  finally  spreads  throughout  the  body  and  the  limbs.  This  pain  is  aggra- 
vated l)v  movements  of  the  trunk  or  by  movements  of  the  limbs,  but  is  not 
usually  associated  with  any  distinct  tenderness  of  the  spinous  processes.  Evi- 
dences of  motor  irritation  appear  usually  in  a  very  few  hours  in  the  form  of 
violent  tonic  spasms,  most  marked  at  first  in  the  back,  but  soon  involving  the 
extremities.  Tlie  contractions  are  usually  severe  enough  to  produce  opistho- 
tonos or  other  forced  position  of  the  trunk,  and  to  set  the  limbs  in  rigid  flexion. 
The  pain  produced  by  any  attempt  at  motion  gives  an  a])pearance  of  paralysis, 
but  until  late  in  the  disorder,  when  the  nerve-roots  have  been  almost  destroyed 
or  the  cord  itself  involved,  there  is  little  true  loss  of  power.  The  reflexes  are 
grossly  exaggerated  ;  retention  of  urine  and  constipation  commonly  develop 
early.  Hypersesthesia  is  in  most  cases  an  early  symptom,  but  late  in  the  dis- 
ease may  give  way  to  or  coexist  with  ausesthesic  patches.  Consciousness  and 
intellection  are  not  affected  in  the  e'arly  stages,  but  there  may  be  delirium  or 
even  coma  before  death. 

Acute  spinal  meningitis  may  kill  in  two  days,  but,  if  the  patient  survives  a 
week,  is  prone  to  end  in  recovery,  with  more  or  less  permanent  disablement 
from  contractions  and  paralyses  due  to  injuries  of  the  spinal  nerve-roots.  The 
fatal  result  may  be  produced  by  the  rise  of  temperature,  which  is  often  exces- 
sive, or  may  bo  due  to  ])aralysis  of  respiration  or  of  deglutition, 

Diag-nosis. — The  only  disease  with  which  spinal  meningitis  can  readily  be 
conf"ounde<l  is  rheumatism.  The  rapid  development  of  the  symptoms,  the  uni- 
versality of  the  pain  and  spasm,  the  widespread  hypersesthesia,  the  exaggeration 
of  the  reflexes,  and  the  general  severity  of  the  attack,  stigmatize  the  spinal 
disease. 

Prog-nosis. — The  prognosis  should  always  be  guarded  in  proportion  to  the 
severity  of  the  symptoms. 

Treatment.— The  treatment  of  acute  spinal  meningitis  should  be  most 
actively  antiphlogistic.  Free  venesection,  general  or  local ;  free  purgation  by 
means  of  calomel,  followed  by  the  rapid  induction  of  ptyalism  by  mercurial 
inunction  ;  the  use  of  very  active  counter-irritation  over  the  back, — these  meas- 
ures find  f  heir  justification  in  the  seriousness  of  the  local  disease,  and  in  the  fact 


CHROXIC  SPINAL    MEXIXGITIS.  743 

that  inflaiiimations  of  serous  membranes  are  much  more  readily  influenced  by 
such  treatment  than  are  parenchymatous  inflammations.  Absolute  quiet  and 
rest  should  be  enjoined.  The  food  at  first  should  be  liquid,  non-stimulating, 
and  moderately  nutritive,  but  afterward  should  be  both  nutritive  and  stimula- 
ting; and  during  convalescence  the  most  absolute  care  must  be  enjoined  to  pro- 
tect from  any  chilling  of  the  surface  or  any  fatigue  of  the  nervous  or  muscular 
system. 

Chronic  Spinal  Meningitis. 

Definition. — A  dironic  inflammation  of  the  spinal  membranes. 

(,'hronic  spinal  meningitis  may  occur  as  a  local  or  as  a  widespread  disorder. 
The  most  impc^rtant  local  form  is  that  originally  described  by  Charcot,  and 
commonly  known  as  cervical  pachymeningitis,  an  affection  in  which  the  incm- 
branes  of  the  cervical  spinal  cord  are  found  after  death  enormously  thickened, 
compressing  the  cord  and  involving  the  nerve-roots.'  Two  stages  of  the  dis- 
ease are  recognized  :  first,  that  of  irritation  ;  second,  that  of  paralysis ;  but  it 
must  be  remembered  that  the  separation  of  these  two  stages  is  in  fact  artificial. 
Pain  in  the  back  of  the  neck,  extending  into  the  head  and  along  the  arms,  asso- 
ciated with  stiffness  and  muscular  weakness  of  the  parts  and  increased  by  move- 
ment, constitutes  the  chief  sympton^  of  the  first  stage.  Vesicular  or  otiier 
trophic  skin  lesions  due  to  inflammation  of  the  nerve-roots  are  often  present. 
The  second  or  paralytic  period  is  characterized  by  loss  of  muscular  power,  with 
muscular  atrojihv  especially  affecting  the  domain  of  the  ulnar  and  median 
nerves,  and  followed  by  contractures  which  extend  the  hand  and  the  forearm 
and  flex  the  fingers  into  a  claw-like  position.  The  disease  may  finally  ascend 
upward  and  downward,  and  give  rise  to  widespread  symptoms  of  chronic  men- 
ingitis. Cervical  pachymeningitis  is  probably,  in  a  majority  of  cases,  specific, 
and  certainlv  should  always  be  treated  with  mercury  and  the  iodides  until  their 
lack  of  efficiency  is  demonstrated.  Very  severe  repeated  counter-irritation  is 
also  indicated.  In  the  advanced  disease,  when  the  nerve-elements  have  suffered 
great  change,  no  treatment  is  of  avail. 

Generalized  chronic  spinal  meningitis  is  exceedingly  rare,  save  as  the  out- 
come of  syphilis,  traumatism,  or  alcoholism.  It  is  to  be  recognized  by  the 
slowness  of  its  course  and  the  existence  of  symptoms  similar  to  those  of  acute 
meningitis,  due  to  implication  of  the  nerve-roots.  Pain  in  the  l)ack  and  limbs, 
increased  by  active  or  ])assive  movements  ;  hypertesthesia,  perhaps  associated 
with  spots  of  anaesthesia  ;  heightening  of  the  reflexes,  or  in  advanced  stages 
loss  of  the  reflexes  ;  muscular  contractions,  followed  by  loss  of  jwwer  and 
wasting   of    the    nniscles, — these   are    the    most    important    of    the    i)ositive 

symptoms. 

Treatment.— The  treatment  of  ehn.iiic  spinal  meningitis  should  consist 
in  the  lon<'--contiiHie(l  use  of  counter-irritants ;  in  the  administration  ol  llie 
mercurials  and    iodides;  in   absdliitc   icst,  associated  with   access  in  the  open 

'  ("hronics|)inal  jiacIiymeniiipitiH  and  chronic  spinal  KptoineninKiti.s  cannot  be  separated  from 
one  another,  either  clinically  or  anatomically. 


744  ORGANIC  DISEASES    OF    THE  SPINAL    CORD. 

air  ;  and  in  the  maintenance  of  health  by  all  hygienic  means.  In  all  forms 
of  meningitis  opiates,  antipyrin,  and  other  analgesic  remedies  are  to  be  used 
for  the  relief  of  pain. 

Concussion  of  the  Spinal  Cord. 
The  spinal  cord  is  liable  to  have  its  functions  temporarily  suspended  by 
mechanical  violence,  being  in  this  respect  entirely  similar  to  the  brain.  This 
sudden  arrest  of  function  may  pass  oif  in  from  a  few  minutes  to  a  few  hours, 
and  leave  behind  it  no  trace  of  its  former  presence,  or,  if  it  has  been  accom- 
panied by  structural  alterations,  may  be  the  starting-point  for  various  chronic 
inflammations  of  the  cord  itself  or  of  its  membranes.  The  most  absolute  rest 
should  of  course  be  enjoined  at  the  time  and  for  some  days  subsequent  to  the 
injury,  but  there  is  no  specific  medicinal  treatment.  The  term  concussion  of 
the  spine  is  used  by  many  authors  as  the  name  for  the  state  which  frequently 
follows  injuries  to  the  back — a  condition  which  will  be  found  treated  of  in  a 
later  section  of  this  book  under  the  heading  of  the  *'  Remote  Eifecls  of 
Traumatism  to  the  Nervous  System." 

Anemia  of  the  Spinal  Cord. 

Changes  in  functional  activity  are  always  associated  with  corresponding 
changes  in  the  blood-supply  of  the  organ,  but  the  changed  activity  is  com- 
monly the  cause  of  the  changed  vascularity,  not  the  changed  vascularity  the 
cause  of  the  changed  activity.  Nevertheless,  the  relations  between  function 
and  local  circulation  have  created  a  marked  tendency  in  the  professional  mind 
to  attribute  all  irregular,  not  readily  explained  functional  disturbances  to  sup- 
posititious alterations  of  the  local  circulation.  As  an  example  of  this  may  be 
cited  the  hysteroidal  disease  which  is  frequently  spoken  of  as  spinal  ancemia, 
although  there  is  not  any  proof  that  the  alleged  spinal  ansemia  exists,  or  that 
an  existing  anoemia  would  be  capable  of  producing  the  symptoms  present  in 
the  disease.  It  is  a  known  physiological  fact  that  excessive  general  hspmor- 
rhage  will  occasionally  produce  partial  paraplegia,  which  if*  recovered  frani 
when  the  blood-loss  is  made  up ;  also,  that  partial  paraplegia  sometimes  imme- 
diately follows  excessive  purgation  ;  and  a  natural  explanation  of  such  para- 
plegias seems  to  be  lack  of  food-supply  for  the  motor-centres  of  the  spinal  cord. 
In  profound  ana3mia  slight  tingling  and  numbness,  with  partial  loss  of  muscu- 
lar power  in  the  legs  and  arms,  is  sometimes  seen,  but  if  during  an  anaemia  a 
paralysis  becomes  complete,  it  is  probably  always  hysterical  or  due  to  organic 
change. 

The  loss  of  functional  activity  of  the  spinal  cord  which  follows  haemorrhage 
is  to  be  treated  by  rest  in  bed,  as  free  a  diet  as  the  digestive  organs  will  assimi- 
late, and  the  exhibition  of  iron,  strychnine,  and  bitter  tonics. 

Hyperemia  of  the  Spinal  Cord. 
Tlie  plexus  of  veins  which  surround  the  spinal  cord  is  so  large  that  it  is 
prol)ably  possible  for  the  function  of  the  cord  to  be  interfered  with  by  an 


SPINAL    APOPLEXY.  745 

excess  of  blood  in  the  extra-spinal  venous  circulation.  In  addition  to  this, 
analogy  points  out  that  the  spinal  cord  nuist,  like  every  other  organ,  be  liable 
to  acute  hypersemia  with  disturbance  of  function.  There  does  not  seem,  how- 
ever, at  present  to  be  any  way  of  positively  recognizing  during  life  the  con- 
dition of  the  circulation  in  the  cord.  It  is  probaljle  that  many  of  the  synip- 
t(»ras  of  the  condition  known  as  neurasthenia  are  really  the  outcomes  of  passive 
congestion,  and  it  is  entirely  possible  that  cases  reported  as  instances  of  ascend- 
ing paralysis  have  been  really  cases  of  congestion  of  the  cord.  I  have  certainly 
seen  death  under  such  circumstances,  and  found  at  the  autopsy  absolute  fulness 
of  the  vessels  with  serous  exudation.  Again,  I  have  seen  cases  in  which  there 
were  rapidly  developed,  either  without  apparent  cause  or  after  excessive  exer- 
tion with  exposure,  numbness,  with  marked  loss  of  power  in  the  limbs,  with 
lessening  of  reflex  activity,  but  without  the  symptoms  going  on  to  comjilete 
paralysis  of  motion  or  reflexes.  That  excessive  functional  activity  and  its 
consonant  excessive  congestion  may  result  in  pathological  change  is  shown  by 
those  cases  in  which  excessive  coitus  has  been  immediately  followed  by  haemor- 
rhage into  the  cord  ;  and  probably  in  sexual  exhaustion  local  weakness  of  the 
blood-vessels  in  the  lumbar  cord  due  to  their  frequent  distension  during  the 
excessive  coition  is  an  influential  factor. 

In  cases  in  which  the  symptoms  point  toward  congestion  of  the  spinal  cord, 
if  the  patient  be  robust,  it  may  be  necessary  to  draw  blood  from  the  arm.  In 
other  cases  wet  and  dry  cupping  along  the  vertebral  column  may  be  of  value. 
As  no  evil  results  can  come  in  these  cases  from  moderate  loss  of  blood,  it  is 
better  for  the  physician  to  err  on  the  side  of  too  free  bloodletting.  This  blood- 
letting, however,  is  only  to  be  practised  in  the  first  few  hours  of  the  attack. 
Later,  absolute  rest  on  the  side,  not  on  the  hack,  should  be  prescribed,  and 
ergot  should  be  given  in  large  doses,  the  extract  being  preferred,  as  being  the 
least  apt  of  all  the  preparations  to  produce  gastric  disturbance.  Ten  grains 
of  it  may  be  administered  every  two  hours,  the  dose  after  several  days  being 
reduced.  In  the  very  beginning  of  an  attack  hypodermic  injections  of  the 
extract  of  ergot  may  be  advantageously  given,  so  as  to  make  the  first 
impression   as   rapidly   as   possible. 

Spinal  Apoplexy. 

Definition. — Haemorrhage  into  the  sjiinal  cord,  not  occurring  as  secondary 
to  inflammatory  or  blood  diseases,  pntducing  motor  and  sensory  paralysis 
below  the  point  of  lesion. 

Synonymr. — Hacmatomyclia  ;  Intraspinal  lifcniorrhage. 

Etiology. — ITicmorrhagc  into  the  spinal  cord  is  not  I'arcly  found  after 
death  from  tetanus,  stryclinic  convulsions,  and  diseases  or  accidents  which 
liavc  produced  rapid  asj)liyxia.  Such  litcmorrhages  aif  mere  accidents  ol'  the 
case,  and  are  spoken  of  as  accfSHorif.  '^FlKy  arc  usually  not  to  be  recognized 
during  life.  Local  itiflammations,  tiini(»rs,  or  oilier  organic  diseases  of  (lie 
intravertebral  contents  may  give  rise  to  spinal  liaMiioirliages  which  are  spoken 
of  as  Hecondary.      The  name  of  "spinal   ai)o|)Je\y"  shoidd   be  reserved   for 


746  ORGANIC  DISEASES    OF    THE  SPINAL    CORD. 

cases  in  which  the  haemorrhage  is  acute  in  its  attacks,  sufficient  in  its  amount 
to  produce  distinct  symptoms,  and  not  preceded  by  obvious  organic  disease, 
altliough,  as  in  the  case  of  cerebral  apoplexy,  the  haemorrhage  is  in  a  certain 
sense  secondary,  being  probably  always  the  result  of  previous  disease  of  the 
coats  of  the  blood-vessels. 

The  sym])toras  of  hsematomyelia  develop  with  great  suddenness,  and  may 
be  attended  with  a  primary  brief  loss  of  consciousness.  Sometimes  the  sub- 
ject falls  at  once,  but  a  sharp,  pricking  pain  is  often  first  felt  in  one  or  both 
extremities,  followed  immediately  or  in  the  course  of  five  or  ten  minutes  by 
loss  of  power,  Avhich  becomes  complete  in  a  very  brief  period.  This  loss  of 
])0wer  is  associated  with  disturbance  of  sensation,  and  usually  the  anaesthesia 
becomes  complete  almost  as  rapidly  as  the  palsy.  The  motor  paralysis  at 
once  occupies  its  whole  territory,  and  does  not  extend  upward.  Pain  in  the 
extremities  is  very  rarely  at  all  violent,  and  never  constant,  though  aching  at 
the  seat  of  haemorrhage  may  be  decided.  The  muscles  are  relaxed,  with  their 
electro-contractility  undisturbed.  The  bladder  and  rectum  become  at  once 
implicated.  The  knee-jerk  and  the  cutaneous  reflexes  are  at  first  not  dis- 
turbed or,  it  may  be,  are  a  little  increased. 

There  are  cases  on  record  in  which  the  first  symptoms  have  been  confined 
to  one  foot,  and  in  which  several  days  have  elapsed  before  the  complete 
paralysis  of  the  other  foot.  The  clot,  under  these  circumstances,  must  have 
been  so  exceedingly  minute  as  not  to  involve  by  direct  pressure,  but  only  by 
secondary  inflammation,  the  whole  structure  of  the  spinal  cord.  At  first  the 
extremities  are  free  from  vaso-motor  disturbances,  but  subsequently  the  vaso- 
motor tone  is  often  completely  lost  and  the  limbs  become  congested  and 
cold. 

Spinal  apoplexy  is  apt  to  be  followed  by  myelitic  degeneration  of  the  cord, 
under  which  circumstances  the  reflexes  are  extinguished  and  trophic  changes 
rapidly  develop,  so  that  muscular  atrophy,  loss  of  electro-contractility,  and 
decubitus  are  common  symptoms  to  be  seen  a  few  days  after  a  spinal 
iiaemorriiaire. 

The  prognosis  in  spinal  apo[)lexy  is  absolutely  grave,  and  no  treatment 
is  of  distinct  value.  After  the  first  hours  great  care  should  be  taken  to 
prevent  the  development  of  bedsores. 

Spinal  Embolism  and  Thrombosis. 
Embolic  and  thrombotic  arrests  of  circulation  probably  do  occur  in  the 
spinal  cord,  but  except  as  complications  of  specific  or  inflammatory  disorders 
are  among  the  rarest  of  clinical  phenomena.  Thrombosis  would  probably 
])roduce  symptoms  similar  to  those  caused  by  haimorrhage  into  the  cord,  but 
its  diagnosis  during  life  is  impossible.  The  sudden  occurrence  in  a  case  of 
valvular  iieart  disease  of  paraplegia,  followed  by  symptoms  of  softening  and 
<lestruction  of  the  cord  (such  as  complete  paralysis  of  motion  and  sensation, 
bedsores,  and  other  trophic  changes,  paralysis  of  bladder  and  intestines), 
would  justify  the  diagnosis  of  embolism. 


SPIXAL    TrJIOIiS.  747 

White  Softening  of  the  Spinal  Cord. 
Arrest  of  circulation  in  the  spinal  cord  must  produce  a  true  necrobiutie 
softening,  in  which  the  nerve-tissue  would  break  down  with  hyperteniia  and 
discoloration.  White  softening  of  the  spinal  cord  does  occur,  and  is  thougiit 
to  be  commonly  if  not  invariably  the  result  of  a  myelitis.  It  is,  however, 
somewhat  difficult  to  perceive  how  white  softening  can  represent  a  stage  of 
inflammation,  though  it  is  very  conceivable  that  it  may  be  caused  by  inflam- 
matory products  or  inflammatory  tissue-changes  interfering  with  the  circula- 
tion in  neighboring  territory.  Be  this  as  it  may,  the  explanation  of  Dr.  C.  L. 
Dana,^  supported  in  one  case  at  least  by  microscopic  examination,  that  wide- 
spread degeneration  of  blood-vessel  walls  by  interfering  with  blood-supply 
causes  spinal  white  softening,  has  much  of  plausibility.  The  symptoms  in  a 
case  of  such  softening  would  be  simply  those  of  progressive  ])aralysis  of  all 
the  spinal  functions,  without  evidences  of  spinal  irritation,  and  without  fever 
or  other  constitutional  disturbance  save  exhaustion. 

Spinal  Abscess. 

Abscess  of  the  spinal  cord,  excluding  the  minute  focal  collections  of  debris 
sometimes  occurring  in  myelitis,  probably  exists  ojily  as  the  result  of  a  septic 
meningitis  or  meningo-myelitis.  Even  in  this  form  it  is  of  great  rarity,  but 
raay  be  suspected  when  rapid  and  severe  spinal  symptoms  develop  during  a 
se])ticfemia. 

The  prognosis  is  of  the  gravest  character,  and  there  is  no  known  treat- 
ment capable  of  at  all  modifying  the  course  of  the  disease. 

Spinal  Tumors. 

Non-malignant  tumors  of  the  spinal  cord  are  only  to  be  diagnosed  by  the 
svmptoms  which  they  produce  through  pressure  upon  the  spinal  cord  and  the 
nerve-roots.  This  pressure  may  be  so  extreme  that  the  cord  is  reduced  to  a 
flattened  band,  and  in  many  cases  in  which  there  is  no  great  encroachincut 
upon  the  spinal  canal  the  transverse  meylitis  which  is  set  up  completely  cuts 
off  the  function  of  the  cord.  The  symptoms  vary  according  to  the  size  of  tiu^ 
tumor,  its  position,  its  rapidity  of  growth,  and  its  tendency  to  inflame  nerve- 
roots  and  spinal  tissue.  These  symptoms  can  best  be  studied  as  "  cord-symp- 
toms "  and  "  root-symptoms." 

The  cord-sym])toms  are  sharply  limited — loss  of  motion  and  sensation,  with 
heightening  of  the  reflexes,  and  without  trophic  changes.  If  the  tumor  be  of 
very  slight  growth,  one  side  of  the  spinal  cord  may  be  pressed  down  so  as  to 
lose  its  functional  power  much  earlier  than  the  other  part ;  indeed,  one  function 
of  one-half  of  the  cord  may  be  primarily  affected,  hi  this  way  a  sensory  or 
motor  ])aralysis  or  a  sensory  and  motor  nnnioplegia   may  result    from  a  tumor. 

The  root-symptoms  are  most  serious  in  those  cases  in  which  the  growth  has 
a  tendency  to  set  uj*  inflammatory  changes  in  the  nerve-roots.  Hence  they  arc 
mu<;h  more  severe  in  cancerous  than  in   other  spinal  tumors;  indeed,  the  con- 

'  Joum.  Nerr.  ami  Mtniltd  DtHeajfex,  Sept.,  1K90. 


748  ORGANIC  DISEASES    OF    THE   SPINAL    CORD. 

dition  known  as  spinal  ansesthesia  dolorosa  is  almost  characteristio  of  cancer. 
The  root-symptoms  consist  chiefly  of  sensory  disturbance,- loss  of  power,  con- 
tractures and   atrophy  of  the  muscles,  with   change  of  the  electro-muscular 

contractility. 

The  pain  caused  by  a  tumor  may  be  slight  or  may  be  atrocious.  It  varies 
in  character :  sometimes  it  is  constant,  usually  it  is  more  or  less  paroxysmal ; 
a  steady,  heavv  localized  ache  deep  in  the  back  usually  indicates  involvement 
of  vertebrse,  the  nerve-root  pains  being  burning,  lancinating,  tearing,  or 
"  claw-like."  Usually  the  pain  follows  the  course  of  the  nerves,  shooting  out 
to  their  utmost  distribution  and  girdling  the  body  in  an  agony.  Unless  the 
growth  be  so  low  down  as  to  affect  the  cauda  equina  or  be  high  up  in  the 
neck,  the  pains  are  felt  chiefly,  if  not  exclusively,  in  the  trunk.  When  the 
changes  in  the  nerve-roots  have  progressed  far  enough,  complete  anaesthesia 
may  develop  and  yet  the  pain  be  in  no  way  abated — ancesthesia  dolorosa. 

Diag-nosis. — The  diagnosis  of  compression  of  the  spinal  cord  by  a  tumor 
rests  upon  the  consentaneous  development  of  sensory  and  motor  paralysis, 
without  trophic  changes  or  loss  of  reflexes,  and  the  abrupt  limitation  of  this 
paralysis  by  a  narrow  zone  of  partial  palsy.  In  other  words,  the  connection 
between  the  cord  and  the  brain  is  severed,  and  an  abrupt  line  of  motor  and 
sensory  paralysis  marks  the  seat  of  the  separation  of  conduction.  Trophic 
changes  can  only  occur  in  such  a  case  as  the  result  of  a  secondary  lesion  of  the 
cord.  The  distinction  between  a  tumor  and  the  development  of  a  transverse 
myelitis  by  spinal  caries  is  to  be  made  out  by  noting  the  slowness  of  develop- 
ment of  the  tumor  and  the  lack  of  tenderness  upon  direct  or  indirect  pressure 
upon  the  vertebrae.  If  the  growth  be  very  snjall  and  only  slightly  affect  the 
cord,  the  diagnosis  must  be  one  of  inference.  Transverse  myelitis  does  not 
produce  a  pain  compared  to  that  caused  by  an  extending  spinal  tumor,  but  the 
cause  of  a  transverse  myelitis  may  often  set  up  inflammation  in  the  sensory 
nerve-roots,  with  its  consequence — atrocious   pain. 

There  is  no  known  medicinal  treatment  for  a  non-specific  spinal  tumor. 

Acute  Ascending  Paralysis. 

Definition. — An  acute  disease,  of  uncertain  pathology,  characterized  by  the 
rapid  spreading  of  a  motor  paralysis,  commencing  in  the  lower  extremities, 
and  in  a  very  short  time  involving  the  whole  muscular  system ;  without 
trophic  disturbance  or  alteration  of  the  electro-excitability  of  the  muscles,  and 
with  only  minor  sensory  disturbances. 

Synonym. — Landry's  paralysis. 

Etiolog-y. — The  causes  of  acute  ascending  paralysis  are  at  present  very 
obscure,  unless,  as  seems  probable,  the  disease  is  due  to  a  micro-organism.  The 
victims  are  usually  persons  in  middle  life,  males  more  commonly  than  females. 
In  some  cases  the  attack  has  followed  excessive  exposure  ;  still  more  frequently 
it  has  come  on  after  one  of  the  infectious  diseases.  A  number  of  cases  are 
rei)orted  in  literature  resembling  acute  ascending  paralysis  in  which  syphilis 
has  been  assigned  as  the  cause,  and  in  some  of  which  recovery  has  been  reached 


ACUTE   ASCEyDTXG    PA  n  A  LYSIS.  740 

by  antisvphilitic  treatment.     These  cases  are,  however,  probably  not  instunees 
of  ascending  paralysis,  but  of  syphilitic  myelitis  or  neuritis. 

Symptomatology. — The  first  manifestation  of  an  attack  of  Landry's  dis- 
ease is  a  sensation  of  numbness  and  weight  in  the  feet,  followed  in  the  course 
of  a  few  hours  by  a  distinct  loss  of  jx)wer.  Sometimes  this  numbness  is  pre- 
ceded by  malaise,  with  paraesthesiaj  for  one  or  two  days ;  in  other  cases  it  appears 
during  ajij^arently  full  health.  The  numbness  ra])idly  mounts,  whilst  the  loss 
of  power  in  the  legs  becomes  more  and  more  perceptible,  so  that  within  a  few 
hours,  or  at  most  a  day,  the  power  of  standing  is  almost  or  altogether  lost. 
Rapidly  the  symptoms  continue  to  increase,  the  trunkal  muscles  becoming  in- 
volved one  after  another,  dyspnoea  from  paralysis  of  the  diaphragm  and  respir- 
atory muscles  coming  on,  motion  failing  in  the  upper  extremities,  deglutition 
becoming  difficult  or  impossible,  the  voice  growing  feeble  and  almost  inarticu- 
late or  being  in  some  cases  entirely  suppressed,  and  the  patient  dying,  it  may 
be,  within  two  or  three  days  from  respiratory  paralysis. 

All  of  the  muscles  of  the  body  and. the  extremities  are  thus  paralyzed  in 
this  disease ;  but,  probably  because  death  usually  occurs  before  the  centres  high 
up  in  the  medulla  or  pons  are  reached  by  the  ascending  lesion,  it  is  very  rare 
for  the  muscles  of  the  eyes  to  be  affected,  though  strabismus  and  diplopia  have 
been  recorded.  The  brain-functions  arc  not  interfered  with,  intelligence  and 
consciousness  being  preserved  until  the  last.  The  sensory  symptoms  are  always 
slight.  There  is  no  severe  pain,  only  formication,  numbness,  and  weariness. 
There  may  be  a  little  blunting  of  the  surface,  so  that  a  prick  of  a  pin  is  not 
felt  as  readily  as  normal,  but  any  pressure  or  distinct  contact  is  recognized. 
In  some  cases  sensation  is  somewhat  delayed.  The  sphincters  are  usually  not 
affected,  there  being  no  difficulty  of  urination  or  defecation,  but  the  general 
rule  in  this  respect  is  sometimes  departed  from  late  in  the  disease.  The  reflexes 
suffer  with  the  motor  paralysis,  the  knee-jerk  being  lost  very  early  in  the  attack, 
whilst  the  cutaneous  reflexes,  although  they  may  first  escape,  soon  become  im- 
paired. In  most  of  the  recorded  cases  there  has  been  no  elevation  of  tempera- 
ture, yet  it  may  be  that  a  siiu'ht  initial  rise  has  been  in  these  instances  over- 
looked,  and  in  a  few  cases  which  have  a))peared  to  be  true  Landry's  paralysis 
distinct  elevation  of  temperature  has  been  noted.  Certainly,  however,  absence 
of  marked  fever  is  characteristic  of  the  disease,  and  when  there  is  |»ronounced 
febrile  reaction  the  diagnosis  must  always  be  considered  doubtful. 

The  nuisclcs  preserve  intact  until  the  last  their  normal  electro-contractility, 
and  never  suffer  any  decrease  in  tiieir  bulk,  whilst  the  complete  freedom  from 
decubitus  or  other  evidences  of  trophic  disturbance  shows  how  completely  the 
trophic  centres  escape.  Since  enlai-gcmcnt  of  the  spleen  was  first  noted  by 
Westphal  it  has  been  found  in  a  number  of  cases,  and  it  is  probably  a  constant 
symptom.  Less  constant,  but  probably  present  in  (he  majority  of  cases,  is 
cidargement  (jf  the  lymj)ha(i<'  ghuids. 

Some  cases  have  been  reported  in  which  flic  course  ol'  the  disease  has  not 
been  ascending — in  whi<-h,  indeed,  the  nieihilhi  h:is  heen  the  lir<t  |i;irl  of  the 
cord  to  be  attacked,  so  tiial  speecth,  dcghitition,  and  respiration   have  heeii  pri- 


750  ORGANIC  DISEASES    OF    THE  SPINAL    COMD. 

marily  affected.  In  the  present  uneertainty  as  to  the  real  nature  of  ascending 
paralysis  it  seems  doubtful,  however,  whether  these  cases  should  not  be  con- 
sidered as  instances  of  acute  bulbar  myelitis  or  of  some  other  disease  distinct 
from  Landry's  paralysis. 

Acute  ascending  j)aralysis  usually  runs  a  rapid  course,  terminating  in  death 
in  from  forty-eight  hours  to  a  week.  It  is  not,  however,  always  fatal,  and 
cases  are  reported  in  which  several  weeks  have  elapsed  before  an  alleged  Landry's 
paralvsis  has  reached  its  maximum.  The  recovery  may  be  brought  about  in 
two  wavs :  sometimes  the  ascending  lesion  seems  to  stop  at  a  point  below  the 
respiratory  centres;  in  other  cases  the  paralysis  fails  to  be  complete,  and  perhaps 
after  the  most  alarming  respiratory  failure  power  is  slowly  regained.  Occasion- 
ally recovery  is  rapid ;  usually,  however,  it  is  brought  about  by  a  slow  reversal 
of  the  original  course  of  the  disease,  the  muscles  first  paralyzed  being  the  last 
to  recover  function.  The  recovery  may  be  complete,  but  literature  contains 
numerous  instances  in  which  after  a  supposed  Landry's  paralysis  chronic  spinal 
lesion  with  trophic  or  spastic  symptoms  have  gradually  developed. 

Pathology. — Various  lesions,  especially  focal  myelitic  changes,  slight  men- 
ingitis, and  alterations  in  the  peripheral  nerves,  have  been  described  as  found 
in  cases  of  Landry's  paralysis.  It  seems  certain,  however,  that  these  changes 
have  been  accidental  and  do  not  belong  to  the  disease,  since  the  concomitant 
results  obtained  by  various  highly  skilful  observers  definitely  prove  that  a 
typical  ascending  paralysis  (with  slight  disturbances  of  sensibility,  with  immu- 
nity of  the  sphincters,  without  disturbances  of  the  muscular  contractility)  may 
result  in  death,  without  producing  either  in  the  central  nervous  system  or  in 
tiie  peripheral  nerve-trunks  any  anatomical  alterations  that  can  be  recognized 
by  our  present  methods.  It  is  true  that  sometimes,  when  no  alteration  of  the 
spinal  cord  can  be  determined  by  means  of  the  microscope,  the  existence  of 
excessive  venous  congestion  and  increase  in  the  cerebro-spinal  liquid  suggest 
that  the  pathology  of  the  disease  is  an  acute  congestion  of  the  spinal  cord,  but 
cases  are  not  rare  in  which  no  such  congestion  can  be  made  out. 

Under  these  circumstances  two  theories  of  the  disease  naturally  suggest 
themselves :  first,  that  the  lesion  is  an  inflammatory  congestion  which  leaves 
no  trace  detectable  by  our  present  method  of  investigation  on  account  of  the 
short  time  whi(;h  elapses  between  the  commencement  of  the  disease  and  death  ; 
.second,  that  Landry's  paralysis  is  due  to  a  toxaemia.  The  first  of  these  theories 
is  not  plausible;  the  second  seems  probable.  This  probability  is  increased  by 
the  recent  discoveries  of  the  enlargement  of  the  spleen  and  lymphatic  glands, 
^^•hich  further  suggests  that  the  affection  belongs  to  the  infectious  diseases  and 
is  due  to  the  ])resence  of  micro-organisms.  In  corroboration  of  this  Baumgarten 
and  Curschmann  claim  that  they  have  found  bacteria  in  the  enlarged  glands, 
but  Westphal,  Kahler  and  Pick,  and  others  have  looked  for  them  in  these 
places  without  success.  Centanni^  found  in  a  typical  case  of  Landry's  paralysis 
a  peculiar  bacillus,  which  existed  in  moderate  numbers  in  the  spinal  cord,  but 
in  great  numbers  in  the  peri])heral  nerves,  where  it  formed  colonies  which  had 

'  Ziegler's  Beitracje,  1890. 


ACUTE   ASCEM)jyG    rARALYSIS.  751 

resulted  in  strnotural  alterations  of  the  nerve-fibres,  not  t)t'  the  nature  oi*  neu- 
ritis, but  of  a  neuromycosis.  This  discovery  of  Centanni  has  been  confirmed 
by  Eisenlohr,  who  in  two  cases  found  a  widespread — partially  interstitial,  par- 
tially parenchymatous — alteration  of  the  peripheral  nerves  extending  to  the 
extreme  end-filaments  of  the  nerves,  caused  by  the  presence  of  various  forms 
of  micrococci ;  which  micrococci  also  existed  to  some  extent  in  the  spinal  cord, 
where  they  appeared  to  have  set  up  an  acute  myelitic  process. 

If  Landry's  paralysis  be  a  bacterial  disease,  analogy  indicates  that  atypical 
aberrant  c^ses  will  occur,  and  that  in  prolonged  or  even  in  verv  rapid  cases  the 
changes  in  the  spinal  cord  may  go  beyond  those  ordinarily  produced,  since  it  is 
well  recognized  that  the  symptoms  and  the  extent  of  the  characteristic  local 
lesions  vary  greatly  in  difterent  cases  of  an  infectious  disease.  May  it  not  be 
that  some  of  the  cases  of  alleged  myelitis  have  been  instances  of  Landrv's 
paralysis? 

Diagnosis. — The  combination  of  rapidly  ascending  paralvsis  with  little 
disturbance  of  sensibility  and  loss  of  the  reflexes,  but  without  paralysis  of  the 
sphincters,  trophic  changes,  or  alterations  of  electro-muscular  contractu itv, 
makes  the  recognition  of  Landry's  paralysis  usually  easy.  The  enlargement 
of  the  spleen  and  lymphatic  glands  should  always  be  looked  for,  and  if  neither 
exist,  w'ith  our  present  knowledge  the  true  nature  of  the  disease  must  be  con- 
sidered doubtful.  It  seems  probable  that  several  poisons  may  induce  similar 
spinal  symptoms,  and  there  is  much  plausibility  in  the  supposition  that  those 
cases  of  Landry's  paralysis  that  follow  severe  exposure  may  be  of  rheumatic 
origin.  Evidently  no  enlargement  of  the  spleen  would  be  present  in  a  rliou- 
matic  case,  if  such  case  really  could  exist. 

In  any  individual  case  irregularity  of  the  mode  of  attack  should  raise  a 
suspicion  ;  and  if  high  fever,  pain,  exaggerated  reflexes,  or  trophic  changes 
develop,  the  attack  must  be  considered  to  be  one  of  organic  disease,  jjrobably 
a  central  myelitis  or  a  neuritis.  In  a  peripheral  neuritis  there  would  probably 
be  pain,  and  certainly  tenderness,  over  the  nerve-trunks,  without  enlargement 
of  the  spleen  or  lymphatics. 

Prognosis. — The  prognosis  in  Landry's  paralysis  is  always  very  grave, 
but  cessation  of  ascent  or  failure  of  the  ]>alsy  to  become  complete  woidd 
in  any  case  give  ho])e  of  arrest. 

Treatment. — There  is  no  known  specific  treatment.  Absolute  rest,  with 
careful  feeding,  should  be  strictly  carried  out,  and  any  sym|)tom  that  may  arise 
br*  met.  I  am  not  aware  that  the  effect  of  early  venesection  has  been  carefully 
studied,  l>ut  with  the  ])resent  j)robabiliti('s  of  {\\v.  bacterial  nature  i>f  the  dis- 
ease local  or  general  bloodletting,  and  cvm  severe  spinal  conntcr-irritation, 
seem  scarcely  indicated.  The  free  hypodeiinie  use  of  exirael  of  ernot  for  (lu; 
pin-pose  of  diminishing  sj)inal  congestion  may  be  Juslified.  When  there  is 
any  suspi(,-ion  (jf  rheiuuatic  origin  the  salicylates  should  be  adniinistei-ed  with 
great  freedom. 


752  ORGANIC  DL'SEASE,S    OF    THE   SPINAL    CORD. 


Acute  Myelitis. 

Definition. — An  acute  inflammatory  affection,  involving  the  whole  thickness 
of  a  shorter  or  longer  ]>ortion  of  the  cord,  characterized  by  paralysis  of  motion 
and  of  sensation,  with  trophic  changes. 

Etiology. — Acute  myelitis  occurs  most  frequently  between  the  age  of 
puberty  and  the  fortieth  year  of  life,  and  more  often  in  men  than  in  women. 
It  mav  have  its  origin  in  traumatism,  in  compression  of  the  spinal  cord,  and 
especially  in  the  implication  of  the  cord  in  the  growth  of  thin  inflamed  tissue 
producing  the  pressure.  It  is  asserted  by  authors  to  be  sometimes  due  to 
excessive  sexual  excesses,  especially  unnatural  coitus,  and  sometimes  to  be  the 
outcome  of  excessive  bodily  exertion.  A  much  more  potential  and  positive 
cause  of  tlie  disease  is  exposure,  especially  of  the  overheated  body.  Thorough 
wetting,  sleeping  on  the  snow  or  damp  earth,  etc.  have  in  numerous  instances 
been  immediately  followed  by  an  acute  myelitis.  In  winter  campaigns  it  has 
been  especially  abundant,  probably  induced  by  the  conjoint  efl'ects  of  violent 
emotional  and  physical  excitement,  with  over-exertion  and  extraordinary 
exposure. 

Acute  myelitis  lias  been  noted  as  a  complication  of  various  acute  exanthe- 
mata, diathetic  and  septic  diseases,  and  it  is  said  to  occur  with  great  frequency 
and  severity  among  syphilitic  patients,  though  the  etiological  value  of  syphilis 
is  very  questionable. 

Pathology. — The  macroscopic  changes  produced  in  the  spinal  cord  by 
myelitis  consist  of  alterations  in  color  and  consistency.  Even  whilst  still  in 
its  membranes  the  cord  feels  to  the  fingers  much  softer  than  normal,  or  even 
fluid-like,  and  in  extreme  cases,  when  the  meninges  are  opened,  the  whole 
inner  mass  escapes  as  a  pultaceous  fluid.  If  sufficient  firmness  remain, 
so  that  a  section  can  be  made,  the  surface  of  the  section  will  be  reddish, 
yellowish,  or  brownish,  and  seemingly  structureless,  no  distinction  existing 
between  the  gray  and  the  white  matter. 

The  situation  and  longitudinal  extent  of  the  lesion  varies  indefinitely,  but 
the  dorsal  cord  is  especially  prone  to  suffer.  The  transverse  position  of  the 
softening  also  varies.  In  severe  cases  the  whole  thickness  may  be  completely 
disorganized,  but  the  gray  matter  is  most  universally  and  overwhelmingly 
attacked  ;  hence  the  term  central  myelitis.  Very  often,  instead  of  a  single 
considerable  territory  being  softened,  foci  are  scattered  through  the  cord 
(insular  and  disseminated  myelitis).  The  variations  in  color  chiefly  depend 
upon  the  amount  of  blood  in  the  part;  ruptures  and  necroses  of  capillaries, 
and  even  larger  blood-vessels,  are  inevitable,  and  hence  occurs  the  exudation 
of  altered  blood,  giving  brownish  or  reddish  tints,  and  also  not  infrequently 
the  formation  of  small  l)lood-clots  {hcemorrhagie  myelitis).  The  line  between 
sound  and  diseased  tissue  is  never  abrupt,  each  focal  change  being  surrounded 
by  a  zone  of  diseased  tissue  shading  off  into  the  normal  cord.  AVhen  life  is 
jn-olonged  and  the  acute  disease  merges  into  a  chronic  condition,  the  cellular  or 
neurogliar  tissue  around  the  foci  of  inflammation  undergoes  a  hyperplasia  which 


ACUTE  MYELITIS.  753 

results  in  a  pronounced  sclerosis,  and  the  focal  debris  becomes  surrounded  by 
a  dense  tissue,  or  in  extreme  cases  the  debris  is  finally  absorbed  and  tiie 
sclerosed  tissue  more  and  more  condensed  until  a  thick-walled  cyst  remains. 

Under  the  microscope  all  the  nerve-elements  are  seen  to  have  changed. 
The  multipolar  cells  of  the  gray  matter  at  times  show  uudtii)lication  oi*  their 
nuclei  :  more  commonly  they  are  bloated,  with  their  process  brt)i<en,  siirunken, 
irregularly  enlarged,  or  in  some  way  showing  marked  change  of  form.  Tiie 
cells  become  coarsely  granular,  or,  losing  all  structure,  are  glass-like  in  their 
transparency.  Vacuoles — i  e.  spherical,  transparent,  seemingly  empty,  bub- 
ble-like spaces — can  be  seen  in  many  of  the  cells.  Whether  they  are  present 
during  life  or  are  the  results  of  post-mortem  change  seems  uncertain.  In  all 
affected  parts  the  nerve-filaments  are  found  altered,  swollen,  almost  broken  nj> 
into  strings  of  beads,  the  axis-cylinder  being  especially  prone  to  increase  in 
size  when  the  structural  alteration  has  gone  into  comj^lete  softening. 

The  nerve-elements  are  all  more  or  less  completely  destroyed.  There  are 
left  glistening,  structureless  remains  of  nerve-cells,  bits  of  axis-cylinders  or 
fatty  degenerated  sheaths,  or  altered  nerve-filaments  mixed  with  drops  and 
masses  of  myeline,  large  granule-cells,  altered  blood-corpuscles,  pigment-gran- 
ules, and  a  mass  of  minute  granules  of  unrecognizable  origin.  The  walls  of 
the  blood-vessels  are  thickened,  highly  nucleated,  and  often  filled  with  falty 
granules,  whilst  the  connective-tissue  framework,  if  it  remain,  is  swollen  and 
softened  by  new  cells  and  fatty  changes. 

The  condition  of  the  cord  sometimes  spoken  of  as  gray  myelitis  represents 
an  attempt  at  recovery,  in  which  the  escaped  myelin  and  other  results  of  dis- 
integration have  been  absorbed,  whilst  the  connective  tissue  has  been  increased 
and  hardened  into  the  beginning  of  a  sclerosis.  As  already  stated,  this 
attempted  reparation  may  result  in  the  formation  of  a  cyst  or  of  a  cicatrix, 
but  the  nerve-filaments  have  no  jwwcr  to  undergo  repair,  so  that  restoration 
of  function  is  impossible. 

The  process  whose  anatomical  results  have  just  been  described  is  believed 
by  the  great  mass  of  })athologists  to  be  an  inflammation,  and  in  aa-c^rdance 
with  this  view  three  stages  are  described  :  first,  the  stage  of  hypera^mia  and 
commencing  exudation  {red  softeninc/) ;  second,  the  stage  of  fatty  degencrati(»n 
and  resor|)tion  {yelloio  softening)  ;  third,  the  terminal  stage  (formation  (»l"  cica- 
trices or  cysts,  sclerosis,  etc.). 

The  fact,  however,  that  true  suppuration  probably  never  occurs  in  pure 
myelitis,  but  is  only  found  when  the  meninges  are  involved,  and  the  great 
rarity  of  post-mortems  during  the  stage  of  sim|)le  hyperjL'mia,  have  led  some 
writers  to  deny  that  myelitis  is  in  truth  really  an  inflanunalion  ;  indeed, 
Spitzka  affirms  that,  although  authorities  describe  as  anatomical  alterations  in 
the  first  staire  canillarv  contrestion  and  infiltration  of  the  vasculai-  area,  the 
adventitia,  and  the  neuroglia  with  gramde-eells,  yet  he  has  never  been  able  to 
find  in  literature  a  recorded  case  in  which  these  things  have  actually  been 
be(;n. 

Symptomatology. — The  course  and  symptoms  of  acute  myelitis  vary  so 
Vol.  I. — 48 


754  OBGAXIC  DISEASES    OF    THE  SPINAL    CORD. 

miK'li  within  certain  limits  that  it  seems  best  to  analyze  them  before  speaking 
of  the  course  of  the  disease. 

In  severe,  rapid  cases  of  myelitis  the  fever  develops  very  early,  and  may 
throughout  remain  persistently  high.  Sometimes  the  febrile  reaction  occurs 
in  paroxysms,  and  an  excessive  rise  of  temperature  just  before  death  is  not 
uncommon.  The  fever  may,  however,  even  in  fatal  cases  of  myelitis,  be 
entirely  absent,  and  very  commonly  the  temperature  does  not  rise  above  101°  F., 
whilst  a  primary  fever  often  disappears  during  the  attack.  The  fever  of  the 
myelitis  itself  must  be  distinguished  from  the  fever  which  in  the  later  stages 
is  not  rarely  produced  by  septic  absorjition  from  sloughing  bedsores. 

The  spinal  sym])toms  are  those  of  irritation  and  those  of  paralysis.  The 
symj)toms  of  irritation,  both  motor  and  sensory,  usually  appear  early  in  the 
attack,  and  are  more  or  less  completely  lost  within  a  short  time,  in  some  cases 
to  reappear  when  partial  convalescence  develops.  Twitching  of  the  muscles, 
tonic  or  clonic  contractures,  and  exaggeration  of  the  reflexes  may  be  present ; 
in  some  cases  any  movement  of  the  limbs  produces  violent,  irregular  muscular 
contractions.  Tlie  symptoms  of  sensory  irritation  may  be  mild  or  severe. 
Tingling,  numbness,  violent  formication,  shooting  pains,  excessive  distress 
during  micturition  and  defecation,  have  been  frequently  noted,  and  even  after 
a  complete  abolition  of  sensibility  an  agonizing  anaesthesia  dolorosa  mav 
remain.  Sometimes  the  pain  amounts  to  an  intense  agony — a  burning  girdle 
-of  molten  iron,  a  thrusting  of  superheated  needles  through  the  limbs,  a  drag- 
ging or  tearing  of  muscles  from  the  flesh,  etc.  Pain  in  the  back,  with  exces- 
sive sensitiveness  over  the  spinous  processes,  especially  to  hot  or  cold  appli- 
cations, is  not  rare.  True  hyperesthesia  is  not  common,  but  very  early  in  an 
attack  a  peculiar,  diffused,  painful  vibrating  sensation  may  occur  wdien  the 
part  is  touched  (the  di/scesthesia  of  Charcot).  True  sexual  excitement  is  never 
present  in  myelitis,  but  painful  priapism  is  not  rare  during  the  stage  of  irrita- 
tion, and  may  last  into  the  paralytic  stage. 

The  symptoms  of  irritation  usually  very  rapidly  disappear,  more  or  less 
comi)letely,  in  those  of  paralysis,  the  motor  paralysis  becoming  complete,  the 
nuiscles  being  flaccid,  and  the  limbs  lying  as  though  dead.  The  form  of  the 
palsy  is  usually  paraplegic,  but  it  follows  the  seat  of  the  lesion  and  may  be- 
come universal.  The  paralysis  is  accompanied  with  loss  of  the  reflexes,  the 
knee-jerk  and  the  cutaneous  reflexes  disappearing  entirely.  In  some  cases  in 
the  lower  part  of  the  body  the  paralysis  is  complete  and  the  reflexes  absent, 
whilst  higher  up  exaggeration  of  the  reflexes  shows  that  the  stage  of  irritation 
is  not  yet  i)ast.  The  sjihincters  are  almost  always  involved,  and  retention  or 
incontinence  of  urine  is  often  an  early  symptom. 

The  loss  of  sensation  is  complete,  involving  all  forms  of  sensibility. 
Probably  as  the  result  of  the  involvement  of  nerve-centres  presiding  over 
secretion,  the  excretions  rapidly  become  abnormal.  Thus,  even  in  two  days 
the  urine  may  become  highly  alkaline,  bloody,  rauco-purulent,  and  loaded 
with  the  crystals  of  triple  phosphates,  whilst  the  ijerspiratiun  is  excessive, 
irregular,  and   altered  in  quality. 


ACUTE   MYELITIS.  Too 

Vaso-niotor  \Y,\hy  occasionally  shows  itself  at  fir.^t  in  a  toinporarv  rise  of 
the  temperature  of  the  paralyzed  limbs,  bnt  usually  the  extremities  are  cold 
and  may  be  swollen  In-  a  ditl'use  cedematous  exudation. 

Muscular  atrophy,  with  loss  of  faradic  irritability  and  the  development 
of  the  reactions  of  degeneration,  appears  very  early.  The  troj)hie  bedsore, 
decubitus  aciitus,  Mhich  in  .severe  cases  may  be  unavoidable,  usually  attacks 
the  sacro-gluteal  region,  but  occasionally  appears  in  the  heels  or  other  portions 
of  the  body.  The  first  warning  consists  of  one  or  several  dark-red  or  violet 
erythematous  patches,  variable  in  extent  and  irregular  in  shai>e.  Within 
twenty-four  or  forty-eight  hours  reddish  or  brownish  vesicles  or  bidlje  form  in 
the  central  portions  of  the  erythema.  In  rare  cases,  under  careful  manage- 
ment, the  blebs  wither  and  disa{)pear  without  further  symptoms  ;  usually,  how- 
ever, the  elevated  e])idermis  is  toi'n  or  drops  off,  leaving  a  bright-red  surface 
with  bluish  or  violet  points  or  patches,  and  with  swelling  and  sanguinolent 
infiltration  of  the  surrounding  tissue.  Quickly  the  reddish  surface  becomes 
blackened,  and  a  slough  of  variable  extent  forms.  The  whole  buttock  may 
thus  melt  down  in  the  course  of  a  few  hours.  Sometimes  the  process  is 
arrested  and  the  slough  se]>arates,  but  oftener  the  process  continues,  and,  uidess 
the  patient  die  too  quickly,  the  deeper  muscles,  with  the  nerve-trunks  and 
arterial  branches,  are  laid  bare,  and  finally  the  bones  themselves  appear. 

Distinct  disturbance  of  vision  is  not  common  in  acute  myelitis,  but  con- 
traction of  the  field  of  vision,  amblyopia,  or  amaurosis  due  to  optic  neuritis 
have  been  noted,  and  in  some  cases  the  disturbance  of  vision  has  preceded  the 
outbreak  of  more  ordinary  symptoms. 

Acute  myelitis  varies  indefinitely  in  the  rapidity  of  its  course,  but  three 
types  may  be  recognized  :  the  explosive,  the  acute,  and  the  subacute,  it  being 
understood  that  in   nature  these  grade  one  into  the  other. 

Tiie  foufh'oi/ajit  or  the  explosive  myeliiis  (myelitis  centralis)  connnences 
abruptly,  with  disturbance  of  scMisation,  followed  in  a  few  minutes  or  h(»iirs  by 
<"omplete  anesthesia,  motor  paralysis,  trophic  changes,  and  abolition  of  rcficxes. 
It  is  usually  associated  with  more  or  less  intense  fever,  delirium,  coma,  or  con- 
vulsions. This  central  myelitis  is  often  associated  with  ha}morrhage  into  the 
cord  (hcematoini/elifls),  when  the  paralysis  becomes  complete  in  a  few  minutes. 
In  these  cases  death  may  occur  without  violent  constitutional  symptoms. 

The  acute  myelitis  runs  a  very  rai)id  course,  with  or  without  fever,  the  |)ar- 
alvsis  becoming  (.'omplete  in  from  one  to  two  weeks.  Disturbances  of  the 
cerebration  are  not  a  necessary  symptom  of  acute  myelitis,  but  usually  in 
rapid  cases  fever,  headache,  and  (h.'lirinin   aic  present. 

T\\G  subacute  myelitis  \<  that  in  whi<h  several  weeks  are  re(|uired  for  the 
full  development  of  the  |i;ir;ily,-is  or  in  which  the  paralysis  never  Ix'Cdmes 
absolutely  f^omplete. 

The  e.r/)losive  myelitis  very  fre<|iientiy  end-  in  death  from  paralytic  :is|»hy.\ia 
in  a  verv  fi'W  davs,  or  septic  absorption  I'lMni  deconi|)osing  urine  and  from 
sloutdiiu"-  bedsores  l)rin<'s  about  the  fatal  terminati<in  in  two  or  three  weeks. 
Acute   nivelitis   iisiimIIv  en(l>   in   death    from   septic   fever  and   exhaustion  in  a 


75G  ORGANIC  DISEASES    OF    THE  SPINAL    CORD. 

few  weeks  or  months,  or  occasionally  may  terminate  in  an  imperfect  recovery. 
Subacute  myelitis  may  end  in  death,  but  very  commonly  passes  into  a  con- 
dition of  chronic  myelitis,  in  which  mild  trophic  symptoms  and  partial  para- 
plegia may  exist  for  years ;  or  it  may  end  in  an  imperfect  recovery  with 
atrophies  and  paralysis  in  groups  of  muscles.  In  very  mild  cases  recovery 
may  occur  after  a  prolonged  convalescence. 

Diag-nosis. — The  difficulties  which  hang  about  the  diagnosis  of  myelitis  are 
best  discussed  by  considering  the  different  forms  separately.  The  only  diseases 
M'ith  which  an  explosive  myelitis  can  be  confounded  are  Landry's  paralysis  and 
haemorrhage  into  the  spinal  cord.  The  myelitis,  however,  is  usually  distin- 
guished by  the  existence  of  decided  fever ;  by  the  pronounced  disturbance  of 
sensation ;  by  the  early  paralysis  of  the  bladder,  and  especially  by  the  early 
coming  on  of  muscular  atrophy,  with  the  reactions  of  degeneration  ;  and  by 
the  diffuse  oedema,  the  sloughing  bedsores,  and  other  trophic  alterations. 
Hiemorrhagic  myelitis  so  closely  resembles  haematomyelia  that  no  less  an 
authority  than  Spitzka  denies  the  existence  of  the  latter  condition  ;  and  when 
headache,  fatal  delirium,  and  other  constitutional  symptoms  are  absent,  it  may 
not  be  possible  at  first  to  make  out  the  myelitis,  which  must,  however,  soon  be 
revealed  by  the  occurrence  of  trophic  changes. 

Acute  myelitis  may  be  confounded  with  certain  forms  of  poliomyelitis,  but 
the  latter  lack  the  pains  and  the  superficial  trophic  changes  in  the  skin  which 
occur  in  myelitis.  From  a  peripheral  neuritis  the  myelitis  is  to  be  distinguished 
by  the  intensity  of  its  paralytic  phenomena,  by  the  rapidity  of  the  development 
of  the  muscular  atrophy  and  other  trophic  changes,  and  by  the  absence  of  ten- 
derness over  the  nerve-trunks. 

In  subacute  myelitis  the  trophic  changes  often  occur  slowly  or  are  altogether 
absent.  Such  a  case,  however,  lacks  the  nerve-trunk  tenderness  and  the  exces- 
sive pain  of  porij)heral  neuritis. 

Treatment. — The  treatment  usually  advised  in  acute  myelitis  is  founded 
upon  the  theory  that  the  lesion  is  inflammatory  and  capable  of  arrest  by  anti- 
phlogistic measures.  Under  this  view  of  the  case,  if  the  patient  be  seen  in  the 
onset  the  most  active  antijihlogistic  treatment  is  justifiable.  If  it  be  possible 
to  arrest  so  serious  a  local  inflammation,  the  fear  of  producing  a  general  exhaus- 
tion should  have  little  consideration.  Unfortunately,  however,  there  seems  to 
be  no  weighty  clinical  evidence  that  the  most  severe  venesection,  use  of  cold,  or 
other  anti])hlogistic  measures,  have  distinct  influence  upon  the  disease.  Never- 
theless, if  the  general  constitutional  condition  be  good,  blood  may  be  drawn 
from  the  arm,  and  active  local  bloodletting,  by  means  of  leeches  or  dry  cups,  is 
usually  advocated  by  authorities.  Ergot  is  commonly  employed  for  the  pur- 
])ose  of  diminishing  congestion,  and,  although  our  knowledge  of  the  actual 
value  of  the  drug  is  imperfect,  its  harmlessness  and  the  possibility  of  useful- 
ness warrant  its  free  administration.  It  may  be  given  in  the  beginning  hypo- 
derm  ically  in  the  form  of  the  extract,  and  afterward  the  extract  may  be 
administered  in  doses  of  ten  to  fifteen  grains  every  three  hours,  until  disturb- 


ACUTE   MYELITIS.  757 

anco  of  the  stomach,  ergotic  cohhiess  of  the  surface,  or  the  continuing  progress 
of  the  disease  indicates  its  \vith(h-awal. 

The  production  of  diaplioresis  hv  the  use  of  the  hot  bath  or  hot  pack  is 
especially  recommended  by  Erb  in  cases  in  which  the  premonitory  signs  of 
myelitis  make  their  appearance  after  e.^posure  to  cold,  etc.  ;  but  I  cannot 
believe  that  these  measures  really  avail  anything,  though  they  may  in  various 
cases  have  relieved  rheumatic  pains  and  general  muscular  soreness  following 
exposure,  which  had  been  sujiposed  to  be  precursors  of  myelitis.  During  an 
attack  the  warm  l)ath,  however,  does  appear  to  be  grateful  to  patients  and  to 
render  them  more  comfortable,  and  should  always  be  tried.  In  employing  it 
absolute  precautions  must  be  taken  that  the  patient  himself  make  no  effort 
whatever,  a  sufficient  staif  of  nurses  to  readily  lift  him  being  provided.  The 
temperature  of  the  bath  should  be  in  the  beginning  90°,  to  be  increased  later 
if  it  be  found  advisable.  The  duration  of  the  bath  should  at  first  be  about  ten 
minutes,  but  it  should  be  rapidly  increased  almost  indefinitely,  according  as  it 
is  found  to  agree  with  the  individual  case.  The  bath  may  be  given  once,  twice, 
or  three  times  in  the  twenty-four  hours  as  seems  wisest. 

The  free  use  of  mercurials  has  been  largely  advocated,  usually  on  theoretic 
grounds.  Certainly,  grave  doubts  surround  the  advisability  of  mercurial- 
ization,  and  if  ptyalism  be  ])roduced  at  all  it  should  be  done  with  great  caution. 
There  is  not  the  slightest  reason  for  supposing  that  belladonna,  derivation  to 
the  intestines,  or  the  production  of  diuresis  by  means  of  the  ingestion  of  large 
quantities  of  alkaline  waters,  as  recommended  by  Erb,  are  of  any  service  what- 
ever. Of  course  if  excretion  fails  from  want  of  nerve-influence,  care  should  be 
exercised  to  see  that  the  emunctories  are  kept  active.  Strychnine  has  been 
recommended  by  high  authorities,  whilst  other  practitioners  (myself  among 
them)  have  found  it  to  do  injury.  If  the  generally  held  views  concerning  the 
nature  of  the  disease  and  the  action  of  strychnine  be  correct,  injury  rather  than 
good  is  t\)  be  expected  from  its  use. 

A  question  which  always  requires  very  careful  consideration  is  as  to  the 
use  of  local  applications  to  the  spine.  The  application  to  the  spine  of  ice  con- 
tained in  a  long  thin  rubber  bag  })ossibly  may  be  of  s^ervice,  and  probably  is 
not  injurious.  Counter-irritation  by  means  of  the  actual  cautery  or  the  blister 
has  been  largely  ])ractised,  and  finds  much  commendation  by  some  writers. 
The  grave  danger,  however,  of  precipitating  ulcers  and  widespread  gangrene 
attends  the  use  of  remedies  of  this  (;lass,  and  certainly  no  counter-irritants 
should  i)e  applied  to  the  skin  which  is  already  distinctly  anjcsthctic  or  to  a 
part  which  may  be  exposed  to  continuous  pressure.  Sjjit/Ua,  on  tiieoretic 
grounds,  believes  that  counter-irritation  applied  to  the  lower  legs  and  feet  is 
of  much  more  service  than  are  the  same  measures  ai)plied  to  the  bacU.  The 
use  of  the  galvanic  current,  as  occasionally  ])ractised,  seems  to  be  an  outcome 
of  a  childish  credulity. 

From  what  has  been  already  saitl  it  will  l»e  seen  thai  the  value  of  drugs  in 
mv(!litis,  save  only  for  the  relief  of  symptoms,  must  be  at  present  considcrwl 
problematic. 


758  ORGANIC  DISEASES    OF    THE  SPINAL. 

The  nursing  during  acute  spinal  inflannnation  is  of  the  utmost  importance. 
So  soon  as  there  is  any  reason  to  suspect  the  commencing  of  a  myelitis 
absolute  rest  in  bed  should  be  prescribed,  and,  so  far  as  possible,  the  patient 
shoukl  be  prevented  from  moving  a  single  muscle  of  the  body,  the  feeding, 
the  making  of  the  personal  toilet,  etc.  all  being  done  by  an  attendant.  This 
absolute  abstinence  from  muscular  movement  applies  not  only  to  the  pre- 
cursorv  stage,  but  is  even  more  important  when  the  symptoms  of  convalescence 
are  developing.  Under  these  latter  circumstances  any  muscular  activity  may 
produce  a  relapse.  In  tiiose  fortunate  cases  in  which  the  patient  recovers  the 
avoidance  of  fatigue  should  be  strictly  enjoined  for  one  or  two  years  after  the 
attack.  What  is  true  of  muscular  movements  during  convalescence  is  even 
more  true  concernino;  the  sexual  functions. 

Various  authorities  lay  stress  upon  the  influence  of  the  dorsal  decubitus 
in  increasing  congestion,  and  consequently  inflammation,  in  the  spinal  cord, 
and  although  it  seems  to  me  that  this  injunction  is  based  upon  a  supersensitive 
theorism,  it  may  possibly  be  correct,  and  the  patient  should  therefore  be  kept 
as  ranch  as  is  convenient  upon  the  side,  or,  according  to  some,  even  upon  the 
face.  If  the  patient  can  be  made  comfortable  in  the  ventral  position,  it  has 
the  advantage  of  removing  from  pressure  those  j)ortions  of  the  body  most  prone 
to  development  of  gangrenous  lesions.  Such  lesions  constitute  one  of  the  most 
serious  complications  of  myelitis,  and  are  therefore  to  be  guarded  against  by 
keepiiig  the  surfaces  perfectly  dry,  by  preventing  pressure,  and  especially  by 
putting  the  patient  on  a  water-bed,  which  should  be  covered  with  one  or  more 
heavy  woollen  blankets  so  as  to  avoid  any  chilling  of  the  body.  If  bedsores 
appear,  they  must  be  treated  according  to  the  ordinary  method,  irritating 
applications  being,  at  least  in  the  early  stages,  avoided,  and  antisepsis  carried 
out  as  thoroughly   as  may  be. 

In  the  very  beginning  of  the  case  it  is  necessary  to  pay  the  strictest  atten- 
tion to  the  condition  of  the  bladder,  as  urinary  retention  and  its  consequent 
cystitis  and  pyelitis  are  so  fre<pient  and  so  fatal.  It  is  probably  better  in  most 
cases  to  use  continuous  catheterization,  along  with  washing  out  of  the  bladder 
once  in  twenty-lbur  hours  with  an  antiseptic  solution.  It  is  always  best  to 
use  the  soft,  flexible  rubber  catheter,  and  in  continuous  catheterization  this  is 
imperative.  The  catheter  may  be  retained  by  adhesive  strips,  but  the  plan 
suggested  by  Si)itzka  of  using  a  perforated  condom  fixed  to  the  catheter  and 
tiien  fastened  to  the  inguinal  region  is  preferable.  To  the  catheter  should 
always  be  attached  a  soft-rubber  tube  ending  in  some  sort  of  urinal.  The 
condition  of  the  bowels  must  always  be  closely  attended  to,  mild  laxatives 
being  emi)loyed,  and  aided,  if  necessary,  by  occasional  stimulating  injections. 

Chronic  Myelitis. 

Definition. — Chronic  inflammation  of  the  spinal  cord,  occupying  more  or 
less  thoroughly  the  whole  transverse  section  of  a  greater  or  less  length  of  the 
coi-d,  and  ])resenting  various  di.sturbances  of  the  spinal  function. 

Etiology. — Chronic  myelitis  may  originate  in  an  acute   myelitis  or  may 


CHROXIC  MYELITIC.  759 

be  espeeiallv  chronic  from  the  beginning.  The  cause  of  it  as  an  original  dis- 
ease appear  to  be  traumatism,  exposures  to  cokl,  sexual  excess,  and  syi)hilis; 
in  a  word,  those  causes  which  when  present  in  more  active  form  or  atlecting 
more  susceptible  individuals  produce  acute  myelitis.  It  is  also  believed  by 
manv  clinicians  that  certain  diseases  of  the  circulation,  as  well  as  propagation 
of  irritation  from  peripheral  nerves  and  irritating  diseases,  may  produce 
chronic  myelitis.  Certainly  there  seems  to  be  some  relation  between  long- 
continued  and  severe  luemorrhoids  and  the  disease. 

Patholog-y. — The  macroscopic  alterations  of  the  spinal  tissue  vary  in 
different  cases  of  chronic  myelitis,  and  it  is  probable  that  several  really 
diverse  affections  are  confounded  under  the  one  name.  In  the  majority 
of  cases  the  chief  alteration  is  sclerosis  or  hardening,  the  substance  of  the 
cord  being  denser  and  firmer  than  normal,  presenting  a  smooth  section  which 
is  often  gravish  or  yellowish  gray,  constituting  one  of  the  conditions  whicli 
has  been  called  gray  dcf/cncnitlon  of  the  cord.  The  membranes  usually  sutler, 
showing  after  death  thickening  or  opacity  or  other  evidences  of  chronic  inflam- 
mation.    The  nerve-roots  also  are  very  frequently  atrophic. 

In  the  sclerotic  tissue  the  neuroglia  is  increased  in  amount  and  density.  It 
contains  an  abundance  of  neuroglia  cells,  many  of  them  enlarged  and  furnished 
with  proliferated  nuclei  and  numerous  ])rocesses  (the  so-called  Dieter's  cells), 
but  it  is  especially  composed  of  wavy,  fibri Hated  l)undles  of  fibres.  The 
nerve-fibres  are  swollen,  often  irregularly  so,  with  sheaths  and  axis-cylinders 
abundantly  and  irregularly  enlarged,  or  are  atrophied,  with  destruction  at  first 
of  the  medullary  sheath  and  afterward  of  the  naked  axis-cylinder.  The 
ganglia-cells  are  variously  altered,  clouded  and  swollen,  or  more  frequently 
atrophied,  shrunken,  indurated,  strongly  pigmented,  or  finally  changed  into 
irregular,  unrecognizable  structures.  Amongst  the  nerve-elements  can  usually 
be  seen  fat  granule-cells,  corpora  amylacea,  and  ])igment-granules,  whilst  the 
walls  of  all  the  blood-vessels  are  enormously  thickened  and  the  perivascular 
spaces  crowded  with  cells  and  exudate. 

In  one  form  of  chronic  myelitis  the  whole  body  of  the  cord  is  filled  with 
moderately  large  neuroglia  cells,  pressing  upon  and  destroying  the  lurvc- 
elements,  but  showing  little  or  no  tendency  to  the  formation  of  fibres.  I 
have  seen  this  form  of  change  usually  in  the  cords  of  ])ersons  who  have 
had    verv  distinct   syphilitic  history. 

Symptomatology. — When  chronic  myelitis  develops  as  a  ])rimary  alfee- 
tion,  it  usually  comes  on  very  insidiously  and  with  marked  fluctuations. 
Slight  sen-sory  disturbances,  parfcsthesia),  partial  aiuvsthesire,  girdle  .sensation, 
I0.SS  of  endurance,  es])e(!ially  in  walking,  and  uncertainty  of  gait  may  develop 
so  slowly  and  with  .so  many  remissions  that  the  subject  .scarcely  kmiws  when 
to  date  the  beginning  of  his  disonk'r.  Constipation,  loss  of  sexual  jtower,  and 
vesical  weakness  may  be  amongst  th<'  earliest  symjytoms. 

In  fully-developed  chronic  myelitis  the  symptoms  resemble  those  *)\'  tlu^ 
acMite  disease,  but  t lie  depression  of  finiclion  usually  predominafcs  over  irrita- 
tion.     Hence  violent  i)aiiis  aii<l  iiiiih  iilar  sjjasms  are  not    iixial,  although  very 


760  ORGANIC  DISEASES    OF    THE  SPINAL    CORD. 

frequently  the  legs  draw  up,  or  attacks  of  vibratile  contractures  in  the  legs 
occur  at  night.  Nevertheless,  although  the  greatest  complaint  is  usually  of 
loss  of  power,  examination  will  almost  invariably  show  evidences  of  irritation 
of  the  spinal  cord  until  very  late  in  the  disorder.  Thus  the  muscles  are 
usually  stiff  rather  than  relaxed,  and  occasionally  when  the  patient  can  still 
walk  the  spastic  gait  of  lateral  sclerosis  is  present  in  a  moderate  degree.  The 
reflexes  are,  in  the  early  stages  of  the  disease,  almost  invariably  exaggerated. 
Often  this  exaggeration  is  very  marked,  the  slightest  touch  upon  the  patella 
tendon,  tickling  of  the  soles  of  the  feet,  or  even  stroking  of  the  thighs, 
provoking  not  only  local  muscular  contractions,  but  also  general  widespread 
movement.  Ankle  clonus  may  be  present.  In  the  later  stages  of  the  affec- 
tion the  reflexes  may  be  diminished  or  even  entirely  lost,  but  this  rarely 
happens  until  the  gray  matter  of  the  cord  is  disorganized,  so  that  it  is  almost 
invariably  associated  with  atrophy  of  the  muscles  or  other  trophic  change 
which  belongs  to  the  last  stages  of  the  disease. 

The  sphincters  are  prone  to  be  involved,  and  vesical  weakness  or  paralysis, 
with  retention  or  dribbling  of  the  urine,  is  almost  universal,  and  is  liable  to 
produce  a  paralytic  cystitis,  which  in  turn  may  creep  up  the  ureters  and 
involve  first  the  pelvis  and  then  the  secreting  structure  of  the  kidneys,  and 
end  in  a  fatal  renal  degeneration. 

The  course  of  chronic  myelitis  is  very  slow  and  prolonged.  The  effect 
upon  the  gejieral  health  of  the  patient  is  in  most  cases  remarkably  slight,  and 
the  bodily  nutrition  may  be  well  preserved  at  a  time  when  the  lower  portions 
of  the  spinal  cord  are  hopelessly  degenerated.  Death  may  be  produced  by 
intercurrent  diseases,  by  trophic  lesions,  by  renal  contraction,  or  in  some  cases 
by  the  sheer  exhaustion  of  prolonged  suffering  and  confinement. 

Diagnosis. — The  diagnosis  in  chronic  myelitis  depends  upon  the  rate  of 
development  of  the  case  and  the  universal  disturbance  of  all  the  functions  of 
the  cord.  Much  more  slow  in  its  oncoming  than  the  acute  myelitis,  it  usually 
lacks  the  years  required  for  the  development  of  true  sclerosis. 

Prognosis. — The  prognosis  of  chronic  myelitis  should  always  be  very 
guarded,  as  recovery  is  rare ;  but  not  infrequently  an  arrest  of  the  disease 
may  be  secured. 

Treatment. — There  is  no  reason  for  supposing  that  drugs  have  much 
influence  over  the  progress  of  chronic  myelitis.  Nitrate  of  silver,  at  one  time 
,  much  used,  has  never  in  my  experience  accomplished  anything.  The  effects 
of  mercurial  treatment  or  of  the  use  of  iodide  of  potassium  are  scarcely,  if  at 
all,  better  marked,  although  I  think  it  often  useful  to  administer  continuously 
corrosive  sublimate  in  the  dose  of  one-sixtieth  to  one-ninetieth  of  a  grain  three 
times  a  day  for  its  tonic  as  Mell  as  alterative  influence. 

Counter-irritation  is  sometimes  useful,  but  to  be  of  any  value  must  be 
.severe.  The  best  form  is  the  application  of  the  actual  cautery,  made  over  a 
considerable  extent  of  the  affected  cord  with  such  light  touches  as  only  to  de- 
stroy the  epidermis.  If  the  part  be  frozen  before  applying  the  cautery,  the 
pain  of  the  application  is  trifling,  whilst  the  after-pain  is  usually  not  so  severe 


ACUTE    POI.IOMYELITIS.  761 

as  tliat  of  a  blister.  Frequent  light  applieatioiis  of  the  cautery  are  of  more 
service  than  severe  applications  at  longer  intervals.  The  Paqnelin  cautery 
has  seemed  to  me  the  best  form,  and  may  be  applied  every  ten  days  or  as  often 
as  the  part  heals.  Hot  baths  or  hot  packs  at  short  intervals  are  often  of  ser- 
vice, and  atford  an  explanation  of  the  reputation  that  certain  thermal  mineral 
>vaters  have  acquired. 

The  hygienic  treatment  is  exceedingly  important,  and  by  change  of  air, 
careful  selection  of  diet,  and  all  other  means  the  general  health  should  be 
improved  as  much  as  possible.  Mental  depression,  over-exertion,  and  fatigue 
are  to  be  sedulously  avoided,  and  as  favorable  a  view  of  the  case  as  possible 
should  be  given  to  the  patient.  Rest  on  the  bed  or  couch  is  often  of  the 
greatest  service,  and  when  conjoined  with  daily  use  of  massage  may  be  main- 
tained for  a  length  of  time  without  endangering  the  general  health  or  pro- 
ducing muscular  relaxation.  When  circumstances  favor  it  the  patient  may 
with  great  advantage  spend  a  large  portion  of  his  time  on  the  bed,  couch,  or 
lounge  in  the  open  air. 

Acute  Poliomyelitis. 

Definition. — An  acute  disease  de])endent  upon  inflammation  or  degeneration 
of  the  ganglionic  cells  in  the  anterior  cornua  of  the  spinal  cord,  characterized 
by  paralysis,  with  complete  relaxation,  rapid  atrophy,  and  alterations  of  the 
electrical  reactions  in  the  affected  muscles. 

Synonyms. — Acute  anterior  poliomyelitis ;  Infantile  paralysis ;  Essential 
paralvsis  of  childhood  ;   Acute  atrophic  paralysis. 

Etiolog-y. — Acute  jwliomyelitis  is  essentially  a  disease  of  childhood, 
although  it  does  occur  during  adult  life.  It  may  appear  in  the  first  month 
of  infancv,  and  about  five-sixths  of  the  cases  arc  developed  in  children  under 
ten  years  of  age.  It  is  indeed  often  claimed  to  be  of  intra-uterine  develop- 
ment, but  the  correctness  of  this  is  doubtful.  It  attacks  males  more  fre- 
(juentlv  than  females.  So  rarely  is  it  possible  to  trace  hereditary  influence 
that  it  appears  not  to  occur  with  abnormal  frequency  in  neuroj)athic  families. 
As  was  first  shown  by  Wharton  Sinkler,  at  least  in  the  climate  of  Philadelphia, 
it  comes  on  more  frequently  during  the  summer  than  the  winter  months.  The 
attacks  have  in  so  many  cases  followed  immediately  upon  ex|)osure  that  it  is 
impossible  to  escape  the  conviction  that  the  exposure  had  been  the  exciting 
cause.  The  same  is  true  of  over-exertion,  es])ecially  over-walking,  in  very 
young  children.  Traumatisms  appear  occasionally  to  atford  the  initial  point. 
Dentition  is  frequently  assigned  as  a  cause,  and  certainly  |)oIiomyelitis  has  in 
numerous  instances  been  a  secondary  result  of  acute  exauthematous  diseases  or 
of  some  local  acute  inflammation  with  high  fever. 

The  explanation  of  the  frequency  of  th(!  disease  in  childhood,  and  of  the 
variabilitv  of  the  exciting  causes,  seems  to  riic  not  far  lo  seek.  The  spinal 
structure  involved  is  trophic  in  its  fnn<;tions,  and  (lining  cliildliood  lias  not 
only  to  maintain  the  nutrition  of  the  muscles  already  developed,  as  it  does  in 
adult  life,  but  also  to  preside  over  growth  and  develoj)ment  in  these  muscles. 


762  ORGANIC  DISEASES    OF   THE  SPINAL    CORD. 

The  functional  activity  in  tliese  parts  must  therefore  be  excessive  during  child- 
hood, and  must  be  attended  with  a  constant  hyperseraia  and  excitement,  which 
make  the  part  liable  to  be  thrown  over  the  line  of  health  by  any  transient 
irritation. 

Patholog-y. — Tlie  one  lesion  which  has  always  been  found  in  modern 
autopsies. in  cases  of  essential  infantile  paralysis  has  been  degeneration  of  the 
multiple  ganglionic  cells  in  the  anterior  cornua  of  the  gray  matter  of  the  spinal 
cord.  Death  is  so  rare  in  the  early  stages  of  the  disease  that  there  are  few 
records  of  post-mortems  occurring  in  other  than  the  fourth  stage.  In  one  case 
reported  by  Dr.  Drummond,  in  which  death  resulted  after  a  few  hours  of  ill- 
ness, the  ganglionic  cells  were  granular  and  swollen — a  condition  which  prob- 
ably represented  the  incipient  stage  of  poliomyelitis.  The  next  change  in  the 
cells  seems  to  be  an  increase  in  the  density  of  the  granulation,  with  pigmen- 
tation :  this  is  followed  by  disappearance  of  the  processes  and  shrinking  of  the 
bodies  of  the  cells  until  they  become  irregular  masses  whose  true  nature  is 
scarcely  recognizable.  Finally,  the  cells  disappear,  so  that  no  traces  of  them 
are  usually  found  in  old  cases.  The  cells  are  attacked  in  foci,  ranging  from  a 
hundredth  of  an  inch  to  more  than  an  inch  in  length.  All  the  cells  in  a  focus 
may  be  aifected,  or  the  destruction  may  be  limited  to  certain  groups  in  the 
anterior,  posterior,  or  other  part  of  the  focus.  The  lesion  of  the  cells  is  so 
constant,  and  is  physiologically  so  closely  related  to  the  symptoms  seen 
during  life,  that  there  can  be  no  doubt  as  to  its  being  the  cause  of  these 
symptoms. 

Two  theories  have  been  and  are  still  to  some  extent  in  vogue  as  to  the 
nature  of  the  lesions  in  infantile  paralysis  :  one  attributes  the  changes  to 
a  primary  idiopathic  atrophy  of  the  ganglionic  cells ;  the  other  teaches  that 
the  cells  are  not  affected  primarily  and  apart  from  the  other  gray  matter,  but 
are  involved  in  a  limited  central  and  focal  myelitis. 

It  would  seem  established  that  in  some  sections  of  the  spinal  cord  in  recent 
cases  of  infantile  paralysis  the  tissue  surrounding  the  cells  appears  normal,  but 
I  do  not  know  of  any  case  in  which  this  condition  has  prevailed  through  the 
whole  length  of  the  affected  region,  and  certainly  evidences  of  hyperseniia  and 
myelitic  changes  in  the  gray  matter  about  the  cells  have  been  very  pronounced 
in  most  of  the  early  autopsies.  In  the  case  reported  by  Dr.  Drummond  intense 
f-apillary  congestion,  with  minute  extravasations  of  blood  and  swelling  of  the 
neurogliar  elements,  were  evident  in  the  gray  matter,  and  in  various  cases  a 
little  more  advanced  than  these  the  investigator  has  found  the  blood-vessels 
dilated,  with  their  lymphatic  sheaths  infiltrated  with  leucocytes  or  surrounded 
by  minute  extravasations  of  blood  ;  the  neurogliar  tissue  swollen,  granular, 
containing  large  round  granular  cells;  the  myelin  of  the  nerve-tubes  broken  ; 
and  indeed  not  rarely  such  general  disintegration  as  to  cause  minute  patches  of 
red  softening.  Our  present  knowledge  trends  in  favor  of  the  theory  that  not 
only  the  motor  ganglionic  cells,  but  also  the  surrounding  tissues,  suffer  in 
poliomyelitis. 

In   old  cases  of  poliomyelitis  the  atrophy  of  the  gray  matter  is  usually 


ACUTE  POTAOMYELITIS.  70:^ 

accompanied  bv  changes  in  the  anterior  nerve-roots  and  in  the  antero-hiteral 
cohnnns  of  the  cord.  The  normal  nerve-tubes  are  wasted,  stripped  of  tlieir 
myelin,  often  without  their  sheaths,  and  are  surrounded  by  hyperplastic 
neurogliar  tissue.  Often  the  parts  are  infiltrated  with  amyloid  corpuscles, 
and  sometimes  the  original  focal  lesion  is  surrounded  by  embryonic  neurogliar 
cells,  looking  as  though  an  attempt  had  been  made  to  isolate  it. 

It  is  not  probable  that  these  changes  are  due  primarily  and  directly  to  the 
original  poliomyelitis,  for  in  no  recent  cases  have  lesions  of  the  white  columns 
been  observed.  It  is  therefore  most  probable  that  these  widespread  spinal  lesions 
are  either  trophic  or  due  to  a  propagation  of  the  inflammation  by  physiological 
or  anatomical  continuity  of  structure.  The  microscopic  changes  seen  in  the 
nerve-roots  resemble  the  degenerative  atrophy  that  follows  section  of  tlu^ 
peripheral  nerve.  Probably  in  a  majority  of  cases  the  nerve-trunks  tiiem- 
selves  undergo  change.  As  was  shown  by  Ijeyden,  this  change  may  consist 
of  a  degenerative  atrophy  or  of  a  neuritis.  The  discovery  of  the  frequency 
of  nerve-trunkal  disease  has  given  rise  to  the  theory  that  neuritis  is  the  cause 
of  infantile  paralysis.  There  can  be  no  doubt  that  many  of  the  symptoms  of 
poliomyelitis  may  be  produced  by  a  peripheral  neuritis.  It  is  also  known 
that  certain  metallic  poisons,  like  lead  and  arsenic,  are  capable  of  originating 
either  a  neuritis  or  a  poliomyelitis  or  a  combination  of  the  two  diseases.  It  is 
therefore  probable  that  in  some  cases  of  disease,  which  we  call  natural  because 
we  are  unable  to  discern  the  cause,  the  poliomyelitis  exists  alone  ;  in  others 
neuritis  exists  by  itself;  whilst  in  others,  again,  both  aflleetions  are  consen- 
taneously developed. 

Symptomatolog-y. — The  onset  of  acute  poliomyelitis  is  almost  invarial)ly 
sudden,  usually  occurring  in  the  midst  of  apparently  robust  health  ;  indeed,  so 
rare  is  any  history  of  a  preceding  nervous  disturbance  that  such  disturbance 
must  be  considered  as  accidental  rather  than  as  prodromic.  The  attack  may 
be  without  constitutional  symptoms,  the  child  perchance  waking  after  a  good 
night's  rest  paralyzed,  or  even  with  apoplectic  abruptness  developing  weakness 
in  the  daytime.  More  frequently  there  is  a  primary  fever  which  is  in  most 
cases  of  moderate  intensity,  although  the  temperature  may  rise  to  104°  F.  The 
duration  of  the  fever  varies  greatly :  sometimes  it  continues  but  a  few  hours,  but 
it  may  persist  three  or-four  weeks.  The  same  variability  is  characteristic  of  the 
cerebral  disturbance:  apathy  grades  in  the  series  of  cases  into  stupor,  and  this 
into  coma,  whilst  restlessness  or  isolated  spasms  pass  into  convulsive  twitchings, 
and  these  into  the  fiercest  of  general  convulsions.  A  most  important  practical 
fact  is  that  there  is  not  a  constant  relation  between  the  severity  of  the  constitu- 
tional disturbance  and  the  extent  or  depth  of  the  subsequent  ])alsy. 

The  sensory  disturi)ance  is  habitually  moderate,  but  pains  in  the  back  and 
limbs  are  often  complained  of,  and  maybe  intense.  Aiiffisthesia  and  liypcr- 
aesthesia  are  so  rare  that  their  existence  should  waken  a  doubt  as  to  the  cor- 
rectness of  the  dia'niosis.  Vomitinjx  may  be  absent,  or  inav  be  so  intractable 
as  to  suggest  that  the  case  is  oii<'  of  gastritis,  'i'hc  i'cvcr  rarely  lingers  long 
after    the    (levehtpment    of  tiie  palsy,    and    may    disappear    with  an    abrupt, 


764  ORGANIC  DISEASES    OF    THE  SPINAL    CORD. 

crisis-like  defervescence.  In  the  majority  of  cases  the  paralysis  is  complete 
before  it  is  recognized,  but,  although  its  coming  on  must  be  very  rapid,  I 
believe  the  extreme  suddenness  of  its  discovery  is  often  due  to  its  having  been 
overlooked.  Certainly  in  a  number  of  cases  a  progressive  paresis,  increasing 
for  from  a  few  hours  to  several  days,  has  been  noted,  and  still  more  often  the 
paralysis,  already  complete  in  one  limb,  has  under  observation  spread  to  other 
parts.  During  the  period  of  acute  constitutional  disturbance  there  is  often 
incontinence,  or  more  rarely  retention,  of  the  urine,  but  true  permanent  paral- 
vsis  of  the  bladder  never  occurs. 

The  situation  and  extent  of  the  paralysis  vary  almost  indefinitely.  Nearly 
the  whole  muscular  system  may  be  so  involved  that  a  true  general  paralysis 
results  and  the  child  be  unable  to  move  hand  or  foot.  The  face  seems,  how- 
ever, to  be  practically  exempt,  permanent  paralysis  of  the  facial  or  ocular 
muscles  due  to  an  acute  poliomyelitis  being,  if  it  ever  occurs,  one  of  the  rarest 
of  nervous  phenomena.  The  same  is  true  of  the  intercostal  muscles  and  of 
the  diaphragm.  The  reason  of  this  exemption  is  not  known,  but  to  it  in  great 
part  is  due  the  fact  that  the  disease  is  so  rarely  fatal. 

The  subsidence  of  the  constitutional  disorder  and  the  development  of  the 
])aralysis  are  followed  by  a  period  of  quiescence,  which  after  from  one  to  six 
weeks  is  succeeded  by  a  peculiar,  almost  pathognomonic,  regression  of  the 
paralytic  symptoms.  The  extent  of  this  regression  varies  so  much  that  there 
is  little  relation  between  the  final  result  and  the  amount  of  original  paralysis. 
The  improvement  occasionally  ends  in  complete  recovery,  but  in  the  majority 
of  cases  after  from  two  to  three  months  spontaneous  amelioration  ceases  and 
some  of  the  muscles  settle  into  permanent  paralysis. 

During  the  second  period  of  the  disease — i.  e.  that  of  widespread  or  general 
paralysis — the  affected  muscles  are  in  a  condition  of  extreme  relaxation,  with 
complete  loss  of  the  reflexes,  and  in  a  very  short  time  a  high  grade  of  rapidly  pro- 
gressive atrophy  manifests  itself,  especially  pronounced  in  those  muscles  which  are 
to  remain  paralyzed,  and  almost  from  the  first  accompanied  by  trophic  changes 
similar  to  those  which  follow  division  of  a  nerve.  The  first  change  is  probably 
modal ;  that  is,  the  muscle  simply  responds  more  slowly  to  galvanic  currents 
ti)an  it  normally  does.  Very  soon,  however,  qualitative  as  well  as  quanti- 
tative changes  a})pear.  In  order  to  detect  these  changes  the  current  must  be 
brought  in  direct  contact  with  the  muscles,  for  if  the  electrode  be  applied  to 
the  nerve-trunk,  it  will  be  found  that  the  electrical  reaction  is  diminished  in 
quantity,  but  not  altered  in  quality.  If  the  negative  pole  {cathode)  of  a  weak 
battery  be  placed  over  a  normal  muscle,  but  not  over  its  motor  point,  a  strong 
contraction  occurs  at  the  closure  of  the  circuit ;  when,  however,  the  positive 
pole  {anode)  is  placed  over  the  normal  muscle,  the  contraction  is  much  less:  in 
neither  case  is  there  any  contraction  when  the  circuit  is  broken  :  in  other  words, 
witli  the  normal  muscle  and  a  feeble  current  we  obtain  good  cathodal  closing 
contraction,  slight  anodal  closing  contraction,  and  no  motion  whatever  at 
either  cathodal  or  anodal  opening.  When  a  current  of  sufficient  power  is  used, 
opening  contractions  are  produced  and  the  anodal  contraction  is  greater  than 


A  CUTE    POLIOMYELITIS.  765 

the  catliodal.  The  "reaction  of  degeneration"  consists  merely  in  a  more  or 
less  })erfect  reversal  of  the  above  formula.  The  anodal  (positive  ])ole)  closure 
then  causes  a  stronger  contraction  than  the  cathodal  (negative  pole)  closure. 
When  there  is  oidy  a  slight  degree  of  degeneration  present  there  is  a  corre- 
spondingly slight  increase  of  anodal  closing  over  cathodal  closing  contraction. 
A  minimum  degeneration  would  be  indicated  by  an  equality  of  the  two  closing 
contractions. 

These  alterations  in  the  electrical  reactions  of  a  degenerating  muscle  are 
readily  formulated,  and  in  this  M'ay  perhaps  wnll  be  more  readily  grasped  by 
the  student.  The  symbols  are  as  follows  :  An  CI  C  represents  anodal  closing 
contraction  ;  An  O  C  represents  anodal  opening  contraction  ;  Ca  CI  C  repre- 
sents cathodal  closing  contraction  ;  Ca  O  C  represents  cathodal  opening  con- 
traction :  <  represents  is  less  than  ;  >  represents  is  more  than  (the  point  of 
the  <  being  toward  the  lesser  quantity). 

Then  the  formulas  are — 

An  CI  C  <  Ca  CI  C  1  ,  i 

»     ^  ^       r^    r^  r^  c  '""sclc  uormal. 
An  O  C  >  Ca  O  C  j 

An  CI  C  =  Ca  CI  C  1  i    •    z-    ,    ,         ^  i 

}•  muscle  m  nrst  stage  oi  degeneration. 

An  U  \^  ^=^  v^a  \j  \y  ) 

^    ^       ^ '  ^     '  >  muscle  in  more  advanced  stage  of  degeneration. 
An  O  C  <  Ca  O  C  )  "=  ^ 

After  the  reaction  of  degeneration  (D  R  of  some  authors)  has  been  estab- 
lished, if  the  muscle  continue  to  undergo  change,  the  galvanic  irritability 
slowly  diminishes,  stronger  and  stronger  currents  being  required  to  produce 
an  effect.  When  a  certain  stage  is  reached  all  reactions  cease  save  a  feeble  An 
CI  C,  and  at  last  this  is  lost  and  the  muscle  does  not  respond  at  all.  When 
recovery  occurs  the  electrical  reactions  of  the  muscle  pass  upwai-d  along  the 
pathway  they  have  descended,' 

The  distribution  of  the  permanent  paralysis  varies  indefinitely,  but  mo- 
noplegias are  much  more  common  than  bilateral  symmetrical  ])aralysis.  A 
more  or  less  complete  crural  paraplegia  is  indeed  often  seen,  but  paraplegia 
cervicalis,  or  paralvsis  of  both  upper  extremities,  is  so  rare  that  its  existence 
has  been  denied.     Even  when  a   bilateral  or  symmetrical  paralysis  occurs,  it 

'  The  diagnostic  importance  of  the  reaction  of  degeneration  is  greatly  lessened  by  tlu-  cir- 
cumstance that  its  demonstration  on  the  person  of  a  terrified  or  enraged  struggling  eiiild 
usually  requires  much  skill  and  patience,  and  that  it  probably  is  never  ]>resent  when  a  muscle 
retains  its  integrity  as  regards  the  faradic  current.  For  the  puri)Oses  of  diaKiinsis  the  failure 
of  response  to  the  rapidly-interrupted  fiiradic  current  is  usually  a  sullicieut  tt'st  of  the  con- 
dition of  a  muscle.  When  a  muscle  loses  its  i)ower  of  responding  lo  the  rapidly-interrupted 
faradic  current  in  a  week  or  ten  days  after  the  occurrence  of  paraly>is,  wlielher  the  reaction  of 
degeneration  can  or  cannot  b(!  satisfacioriiy  detnonslrated,  the  inference  is  positive  that  trojjhic 
changes  are  taking  place  in  the  muscle.  If  a  f<\v  days  later  sudi  muscle  is  unal)le  to  respond  to 
any  faradic  current,  this  inference  becomes  a  certainty.  For  tiie  purpose  of  i)rognosis  the  study 
of  the  reaction  of  degencrati')n  may  be  necessary,  but  it  will,  according  to  my  experience,  often 
be  found  disappointing. 


766  ORGANIC   DISEASES    OF    THE  SPINAL    CORD. 

can  usually  he  made  out  that  the  paralysis  is  really  a  multiple  palsy — that  is, 
is  due  to  the  separate  implication  of  various  centres — because  it  will  be  noted 
that  in  each  involved  limb  certain  groups  of  muscles  escape  altogether  or  in 
part,  and  that  there  is  no  close  correspondence  between  the  affected  groups  in 
opposite  sides  of  the  body. 

Crossed  palsies  and  hemiplegias  are  infrequent  as  a  result  of  poliomyelitis, 
and,  like  paraplegia,  are  to  be  looked  upon  as  formed  out  of  a  number  of 
multiple  palsies.  Indeed,  the  paralysis  of  poliomyelitis  is  a  paralysis  of 
muscle-groups,  and  the  selection  of  the  grouping  seems  to  depend  not  so  nuicli 
upon  the  proximity  of  the  muscles  in  the  limbs  as  upon  their  being  habitually 
used  together  in  the  activities  of  normal  life. 

In  the  description  of  the  symptoms  of  poliomyelitis  I  have  followed  the 
ordinarv  division  into  four  stages:  first,  that  of  constitutional  disturbance; 
second,  that  of  general  paralysis  with  quiescent  symptoms  ;  third,  that  of 
regression ;  fourth,  that  of  the  permanent  paralysis.  This  fourth  stage  is, 
however,  not  a  portion  of  the  disease,  but  a  condition  which  has  resulted  from 
the  disease.  It  is  the  wreck  left  by  the  storm.  The  permanent  paralysis  has 
no  direct  tendency  to  shorten  life,  the  disablement  being  confined  to  those 
organs  which  are  connected  with  locomotion,  the  digestion,  the  general  nutri- 
tion, and  the  sexual  functions  remaining  intact.  The  affected  limb  is  limp  or 
rigid,  often  bluish  in  color  (always,  if  the  paralysis  be  entirely  complete,  hab- 
itually cold),  and  losing  its  heat  with  the  greatest  rapidity  upon  any  exposure. 
The  electrical  reaction  of  the  muscles,  as  well  as  the  atroj)hy,  varies  with  the 
original  lesions.  When  this  is  complete  the  muscles  waste  to  a  fibrous  band, 
incapable  of  responding  to  any  electrical  current.  Other  structures  of  the 
limbs  also  suffer.  The  growth  of  the  bones  is  retarded,  so  that  in  the  growing 
child  gradually  the  arm,  the  leg,  the  hand,  or  the  foot,  as  the  case  may  be, 
becomes  shorter  as  well  as  smaller  than  its  fellows. 

The  interference  with  the  bone  development  is  not  always  in  direct  pro- 
portion to  the  atrophy  of  the  muscles;  indeed,  the  growth  may  be  permanently 
arrested,  although  the  paralysis  entirely  disappears.  Relaxation  of  the  joints, 
due  probably  in  part  to  lengthening  of  the  tendons,  caused  by  the  limbs  drag- 
ging upon  them  whilst  unassisted  by  their  natural  allies,  the  muscles,  becomes 
more  and  more  pronounced  as  the  child  grows  older,  until  at  last  the  head  of  the 
bone  may  be  entirely  out  of  its  socket.  Even  during  the  most  acute  stage  of 
poliomyelitis  bedsores  are  unknown,  and  in  the  chronic  after-condition  there 
are  never  trophic  inflammations  or  destructive  lesions  of  the  skin. 

Various  deformities  arise,  not  simply  from  failure  of  development  of  the 
limb,  but  also  from  the  permanent  shortening  of  the  muscles,  with  consequent 
active  displacement.  The  contractures  which  produce  these  deformities  occur 
chiefly  either  in  muscles  which  have  escaped  entirely  or  have  only  been  par- 
tially affected,  though  there  is  reason  for  believing  that  the  interstitial  devel- 
opment of"  fibrous  tissue  in  the  remains  of  muscles  sometimes  plays  a  part  in  the 
fixation  of  a  joint.  The  contractures  sometimes  appear  as  early  as  four  weeks 
after  the  first  development  of  the  paralysis,  but  are  usually  late  phenomena. 


ACUTE   POLIOMYELITIS.  767 

The  mechanism  of  tlio  production  of  the  deformity  is  (lifferently  viewed 
by  different  observers.  The  orioiiud  tlieory  of  Delpech,  that  it  is  the  out- 
come of  contraction  of  sound  muscles  which  have  shortened  on  account  of 
their  not  being  opposed  as  they  naturally  should  by  their  antagonists,  has  been 
widely  but  certainly  not  universally  accepted.  Another  theory  accounts  for 
the  deformities  by  supposing  that  they  are  due  to  the  influence  of  weight 
upon  joints  from  which  have  been  withdrawn  the  natural  suj)j)ort  of  nuiscles 
and  ligaments.  Thus,  the  weight  of  the  body,  pressing  tinresisted  on  the 
arch  of  the  foot,  which  has  lost  its  natural  stays,  so  to  speak,  gradually  dis- 
places the  bones  from  their  normal  relations,  until  it  entirely  flattens  the  arch 
or  distorts  the  whole  extremity  into  some  form  of  club-foot. 

It  does  not,  however,  seem  possible  to  account  for  some  of  the  deformities 
by  any  theory  of  pressure.  Thus,  how  could  the  drawn,  contracted  fingers 
seen  in  atrophic  paralysis  of  the  forearm  and  hand  be  the  result  of  any  pres- 
sure upon  the  part?  In  the  lower  extremity  pressure  probably  does  have  a 
direct  influence  in  the  development  of  the  club-foot.  Thus,  the  weight  of  the 
body  would  tend  to  produce  in  the  feeble  foot  equino-varus.  It  tends,  there- 
fore, to  intensify  the  action  of  contraction  in  the  sural  muscles  after  paralysis  of 
the  anterior  tibial,  but  to  diminish  the  intensity  of  contraction  of  the  anterior 
group  of  muscles  when  the  gastrocnemius  is  paralyzed.  \u  this  may  be  found 
one  reason  for  the  rarity  of  pes  calcaneus  and  the  comparative  frequency  of 
tali])es  equinus  after  infantile  paralysis.  It  is  probable,  however,  that  the  chief 
cause  of  the  infrequeney  of  pes  calcaneus  after  infantile  paralysis  is  to  be  found 
in  the  flict  that  the  calf  muscles  are  much  less  frequently  affected  than  are  the 
anterior  muscles.  The  most  reasonable  explanation  of  the  production  of  the 
deformities  seems  to  be  tliat  they  are  results  of  several  coacting  or  reacting 
caus(^>^  present  in  varying  degree  in   various  cases. 

The  deformities  of  poliomyelitis  fnay  affect  any  portion  of  the  body.  All 
varieties  of  club-foot,  knock-knees  and  inverted  knees,  rigid  fiexion  of  the 
knees,  cyphosis,  lordosis,  extraordinary  scoliosis,  subluxation  of  the  thighs  or 
of  the  humerus,  claw-like  distortions  of  the  hands, — any  of  these  may  result, 
or  the  withered,  shrunken  limb,  mobile  almost  as  a  rubber  tube,  may  dangle 
from  the  truid<,  an  untoward  memory  of  the  past. 

The  course  and  symptoms  which  have  been  given  of  acute  poliomyelitis 
are  those  seen  in  children.  In  the  rare  cases  in  which  the  disease  occurs  in  the 
adult  the  general  course  is  not  essentially  different  from  that  which  it  holds  in 
childhood.  In  the  first  stages,  however,  the  cerebral  symptoms  are  usually  less 
severe  and  the  vomiting  more  frequent  than  in  very  y<»ung  subjects,  wiiilst  in 
the  fourth  or  last  stage  of  the  disease  the  deformities  are  less  pronounced  than 
in  childhood.  Whether  occurring  in  the  yotu)g  or  the  old,  the  disease  is  essen- 
tially the  same. 

Diag-nosis. — 'i'lie  recognition  ol'  the  ti'ue  nature  of  an  incl|»ieii(  :ittack  of 
polioiuvelitis  with  irrave  constitutional  disorder  is  usually  altended  with  much 
difliculty.  Indeed,  it  is  commonly  iinpossil.le  to  <l(.  more  tiiaii  suspect,  and  such 
suspicion  nmst  rest  upon  exclusion;  as,  this  nttack  i>  for  -udi  :iud  such  reasons 


768  ORGANIC  DISEASES    OF    THE   SPINAL    CORD. 

not  one  of  the  exanthemata,  etc.  etc. :  no  cause  for  ephemeral  fever  can  be 
found,  and  therefore  it  may  be  poliomyelitis.  The  posture  of  habitual  distrust 
upon  the  part  of  the  practitioner  is  exceedingly  important,  as  it  leads  to  watch- 
fulness for  the  appearance  of  paresis.  Whenever  such  paresis  appears  the  diag- 
nosis at  once  becomes  plain.  The  only  affections  which  may  be  confounded 
with  poliomvelitis  in  the  early  paralytic  stages  are  peripheral  neuritis  and 
ascending  paralvsis.  The  completeness  of  the  palsy  and  rapid  alteration  of 
the  electrical  relations  of  the  muscles,  together  with  the  absence  of  nerve-pains 
and  nerve-tenderness,  demonstrate  that  the  case  is  not  one  of  peripheral  neu- 
ritis, whilst  the  course  of  the  paralysis  and  the  occurrence  of  febrile  and  of 
trophic  disturbances  separate  the  aifection  from  Landry's  paralysis.  More- 
over, the  latter  disease  is  extremely  infrequent  in  children,  whilst  acute  polio- 
myelitis is  extremely  infrequent  in  adults. 

Prognosis. — In  the  first  or  active  stage  of  an  acute  poliomyelitis  the  prog- 
nosis has  to  do  with  two  essentially  different  questions  :  first,  as  to  the  danger 
to  life  ;  second,  as  to  the  probable  extent  of  permanent  paralysis.  Death  has 
probably  happened  from  the  grave  constitutional  disorder  that  ushers  in  a  polio- 
myelitis without  the  true  nature  of  the  malady  having  been  recognized,  but 
certainly  death  from  a  recognized  poliomyelitis  is  exceedingly  rare,  so  that  in 
regard  to  immediate  danger  the  prognosis  is  most  favorable.  No  opinion,  how- 
ever, ought  to  be  given  during  the  first  stage  as  to  the  probable  extent  and 
completeness  of  the  permanent  palsy  that  may  result,  since  there  seems  to  be 
no  relation  between  the  severity  of  the  primary  constitutional  disorder  and 
the  gravity  of  the  permanent  disablement.  The  wildest  storm  may  eventuate 
most  happily,  and  the  most  insidious,  development  may  end  in  widespread 
ruin. 

Even  in  the  second  stage,  when  the  paralysis  has  reached  its  maximum,  the 
prognosis  must  be  guarded,  for  although  there  is  a  general  relation  between  the 
severity  of  the  paralysis  of  this  stage  and  the  final  result,  this  relation  is  by  no 
means  fixed  :  a  seemingly  mild  case  may  turn  out  most  unfortunately,  and  a 
very  widespread  and  profound  paralysis  may  clear  up  entirely.  After  the  end 
of  a  week,  if  the  affected  muscles  have  suffered  no  loss  of  faradic  irritability, 
the  prognosis  becomes  very  hopeful ;  if,  on  tiie  other  hand,  the  electrical  rela- 
tions of  the  muscles  are  distinctly  disturbed,  then  long-continued  atrophy  and 
loss  of  function  must  be  expected.  The  earlier  the  electrical  reaction  of  the 
muscles  are  altered  the  more  serious  is  the  prospect ;  and,  vice  iiersa,  if  after 
three  weeks  the  muscles  still  respond  well  to  the  faradic  current,  the  recovery 
will  almost  certainly  be  rapid  and  complete.  When  in  an  advanced  stage  the 
muscles  are  unable  to  respond  to  any  electrical  current,  the  (!ase  is  almost  hope- 
less. When  the  powet*  of  responding  to  the  direct  or  chemical  current  is  re- 
tained, although  the  faradic  current  produces  no  effect,  the  prognosis  becomes 
hopeful  in  direct  proportion  to  the  length  of  time  during  which  the  paralysis 
has  lasted ;  the  longer  the  ])eriod  that  has  elapsed  the  better  is  the  outlook. 
The  preservation  of  the  power  of  reacting  to  galvanic  currents  proves  that  tlie 
spinal  cells  have  not  lost  their  power  of  influencing  to  some  extent  the  nutri- 


r 

^ 


ACUTE  POLIOMYELITIS.  769 

tion  of  the  muscles,  and  affords  ground  f(»rtlu'  liope  that,  aUliouoh  unable  to 
stimulate  the  mu.-^eular  nutrition  to  recover  that  which  has  been  lost,  they  may 
still  be  able  to  hold  up  a  nuiscle  whose  nutrition  has  been  artiiicially  restored. 

Treatment. — When  poliomyelitis  commences  with  violent  general  disturb- 
ance, active  local  or  even  general  antiphlogistic  treatment  may  be  instituted 
witii  the  hope  of  moderating  the  activity  of  the  inflammatory  process,  pro- 
vided the  strength  of  the  patient  be  sufficient.  After  the  paralysis  has  been 
developed  it  may  in  some  cases  be  allowable  to  take  blood  locally  from  the 
back,  but  general  venesection  should  never  be  practised. 

The  proper  treatment  of  the  second  stage  of  the  disease  is  still  an  unsettled 
jiroblem.  With  the  idea  of  diminishing  congestion  and  lessening  inflamma- 
tion authorities  recommend  tlie  ventral  decubitus,  the  continuous  application 
of  cold  by  means  of  ice-bags  along  tiie  spinal  column,  the  administration  of 
ergot,  iodide  of  potassium,  and  mercury,  and  the  use  of  the  actual  cautery  or 
other  violent  counter-irritant ;  in  a  word,  tlie  treatment  of  an  acute  myelitis, 

Erb  and  some  other  authorities  apply  the  direct  galvanic  current  steadily, 
without  interruption  (from  three  to  ten  minutes  by  some  electricians,  or  as 
long  as  several  hours  by  others),  the  positive  pole  being  ])laced  at  the  nape  of 
the  neck,  the  negative  upon  the  lower  end  of  the  spinal  column  or  upon  the 
aflected  muscles. 

There  are  at  least  seeming-lv  sound  theoretical  reasons  in  favor  of  the  anti- 
])hlogistic  method,  but,  as  has  been  shown  elsewhere,  there  is  no  probability 
that  the  galvanic  current  as  applied  to  the  vertebral  column  reaches  the  spinal 
cord,  and  neither  physiological  nor  clinical  data  to  prove  that  if  it  did  reach 
the  cord  it  would  accomplish  any  good.  Its  application  may  sometimes  have 
salutary  mental  effect  uj)on  the  little  patient  and  upon  the  parents,  against 
which  is  to  be  set  tlie  annoyance  of  the  procedure. 

My  own  belief  is  that  in  the  second  or  paralytic  stage  the  treatment  should 
be  largely  expectant,  but  that  extract  of  ergot  should  be  given  in  as  large  doses 
as  the  stomach  will  bear,  and  that  calomel  should  be  cautiously  administered, 
and  the  actual  cautery  be  lightly  but  freely  applied,  provided  that  the  patient 
be  old  enough  and  intelligent  enough  for  it  to  be  used  without  causing  spasms 
of  terror.  In  the  very  young  or  timid,  if  it  be  decided  to  employ  the  cautery, 
ether  ansesthesia  should  be  induced  without  the  patient  knowing  what  is  to  be 
done. 

During  the  stage  of  regression  medicinal  treatment  should  be  limited  to 
the  use  of  tonics  and  the  persistent  administration  of  very  mimite  doses  of 
corrosive  sublimate,  whilst  the  health  of  the  patient  should  be  i)uilt  up  in  all 
possible  ways  and  the  nutrition  of  the  muscles  maintained  by  use  of  electricity, 
massage,  etc. 

In  the  fourth  or  permanent  condition  strychnine  and  phosphorus  maybe 
administered  with  tlie  hope  of  stinndating  ganglionic  repair.  Tendencies  to 
the  development  of  deformities  are  to  be  m<'chanically  combated  and  the 
nuiscles  locally  treated.  In  some  instances  the  iiy|)odcrmic  iujcctiou  oi"  tlie 
strychnine  salts  into  the  paralyzed  nuiscle  has  seemed  to  do  good. 

Vol,.  I.— 49 


77(J  ORGANIC  DISEASES    OF    THE  SPINAL    CORD. 

In  the  local  treatnicnt  of  the  muscles  three  distinct  measures  are  available : 

First :  Mechanical  vibratile  treatment,  combined  with  the  application  of 
heat  (and  ])erhaps  also  of  a  Junod's  boot),  by  means  of  Zander's  or  some 
other  similarly  acting  mechanism  ; 

Second  :  Massage,  and  also  passive  gymnastics  ; 

Third :  Electrical  treatment. 

The  action  of  the  first  of  these  measures  is,  I  have  no  doubt,  of  value  by 
stimulating  the  capillary  circulation,  and  whenever  the  requisite  machinery  is 
at  hand  the  treatment  should  be  carefully  and  persistently  tried  over  some 
months.  Massage  and  passive  gymnastics  have  the  same  aims  as  the  mechani- 
cal treatment  just  spoken  of,  and  are  to  be  used  when  they  can  be  commanded  : 
to  accomplish  anything  at  all  they  must  be  employed  very  persistently  as  well 
as  skilfully.  It  should  be  remembered  that  rubbing  the  skin  by  an  untrained 
person  is  not  massage,  and  does  not,  like  that  procedure,  reach  the  deeper  cir- 
culation :  what  is  wanted  is  kneading  of  the  paralyzed  muscles. 

Electricity  has  been  extensively  employed  in  acute  poliomyelitis  with  very 
widespread  disappointment.  It  is,  however,  a  really  valuable  agent  when 
used  with  a  proper  understanding  of  the  methods  of  its  application  and  the 
limitations  of  its  usefulness.  It  has  no  influence  whatever  for  good  over  any 
of  the  structures  involved  except  the  muscles  themselves,  and  its  application  to 
the  spinal  cord  or  nerve-trunks  at  any  stage  of  the  disease  is  worse  than  use- 
less. In  regard  to  the  time  when  electrical  treatment  should  be  commenced, 
my  own  opinion  is  that  so  soon  as  paralysis  is  detected  electricity  may  be  care- 
fully employed.  At  this  time,  however,  great  caution  is  necessary  to  avoid 
producing  muscular  fatigue  or  any  reflex  irritation  of  the  nerve-centres.  The 
^seances  should  therefore  be  short  and  the  current  only  sufficient  to  produce 
feeble  muscular  contractions.  The  good  accomplished  is  largely,  but  probably 
not  altogether,  due  to  the  functional  excitement  of  the  muscle  by  the  electricity, 
and  consequently  I  have  formulated  the  law  that  the  current  to  be  employed  is 
that  which  will  produce  the  greatest  muscular  contraction  with  the  least  pain. 
This  law  applies  to  all  stages  of  the  disease.  Ordinarily,  the  faradic  current 
fails  entirely,  and  the  direct  chemical  or  voltaic  current  must  be  employed.  It 
must  be  remembered  that  improvement  of  the  muscles  is  of  no  avail  unless 
the  spinal  cord  recovers  its  power,  but  the  effect  of  partial  rehabilitation  of 
the  ganglionic  cells  is  greatly  increased  by  keeping  the  muscles  in  such  a 
condition  that  they  are  able  to  respond  to  whatever  impulse  may  come  from 
these  cells. 

If  the  case  be  first  seen  by  the  neurologist  in  the  advanced  stage,  it  may  be 
taken  almost  for  granted  that  the  amount  of  paralysis  is  greater  than  that  which 
the  state  of  the  cord  necessitates,  so  that  electrical  treatment  offers  a  good  hope 
of  amelioration.  This  is  especially  true  if  the  muscles  have  still  some  power 
of  responding  to  the  electrical  current,  and  even  when  they  seem  at  first  entirely 
dead,  trial  for  two  or  three  weeks  should  be  made,  as  sometimes  muscles  under 
these  circumstances  are  awakened  by  electricity  into  new  life  and  some  volun- 
tary power  is  regained. 


SUBACUTE    on    CHROXIC  POLIOMYELITIS.  771 

111  the  administration  of  the  current  a  single  well-wetted  electrode  should  be 
put  over  the  motor  point  of"  the  muscles,  with  a  larger  electrode  at  a  little  dis- 
tance, so  placed  that  as  much  of  the  muscles  as  possible  shall  be  reached  by  the 
current.  This  procedure  may  be  varied  from  time  to  time  by  ])laciiig  the  poles 
so  as  to  include  between  them  the  whole  length  of  the  muscle.  The  galvanic 
current  may  be  slowly  interrupted,  but  the  eifect  upon  the  muscles  is  much 
greater  if  by  mechanical  arrangement  instead  of  simple  interruption  there  is 
reversion  of  the  current,  so  as  to  make  alternatins;  to-and-fro  currents.  If 
after  eight  weeks  of  electrical  treatment  no  gain  is  achieved,  nothing  is  to  be 
hoped  for. 

In  all  cases  of  infantile  paralysis  it  is  essential  to  prevent,  as  far  as  may  be, 
the  development  of  deformities.  Contractures  are  to  be  overcome,  if  possible, 
whilst  forming  by  thoroughly  stretching  the  muscles  morning  and  evening  with 
the  hand.  When,  in  spite  of  this,  the  contracture  persistently  increases,  section 
of  the  tendons  should  be  resorted  to.  The  operation  is  simple,  without  danger, 
and  experience  shows  that  the  relief  to  the  limb  has  a  distinct  effect  upon  the 
nutrition  of  the  muscles.  So  true  is  this  that  I  think  that  after  such  section  a 
renewed  attempt  to  develop  the  muscles  by  electrical  treatment  should  always 
be  made.  The  application  of  braces  or  other  appliances  to  the  legs  to  aid  in 
locomotion  is  often  imperatively  demanded.  It  is  very  much  better  for  the 
child  to  exercise  the  limb,  even  partially,  than  to  add  to  the  failing  nutrition 
of  spinal  disease  the  depressing  influence  of  loss  of  use. 

Subacute  or  Chronic  Poliomyelitis. 

In  1849,  Duchenne  described  a  peculiar  palsy  of  which  various  cases  have 
from  time  to  time  been  since  reported,  and  which  appears  to  have  very  close 
relations  with  acute  antero-poliomyelitis.  The  symptoms  are  rapidly-(levelo])ed 
paralvsis,  usually  commencing  in  the  l(»wer  extremities  and  extending  u])war(l, 
associated  with  complete  muscular  flaccidity  ;  loss  of  reflex  excitability ;  rapidly- 
progressive  atrophy ;  and  changes  in  the  electrical  relations.  This  disease  is 
said  to  be  distinguished  from  the  acute  poliomyelitis  by  the  absence  of  the 
stages  of  general  stationary  paralysis  and  of  regression,  and  also  by  its  pro- 
gressive course.  It  is  distinguished  from  progressive  muscular  atrojihy  by  the 
paralysis  producing — not  following — the  atrophy,  and  by  the  appearance  of 
well-marked  reactions  of  degenerations  early  in  the  case,  as  well  as  by  the  loss 
of  the  reflexes.  Undoubtedly,  cases  of  neuritis  have  in  the  jiast  been  reported 
as  instances  of  subacute  poliomyelitis,  but  they  are  to  be  distinguished  by  the 
nerve-pain  and  tenderness. 

When  subacute  poliomyelitis  shows  a  distinct  tendency  to  ascend,  there  is 
alwavs  grave  danger  to  life  by  implication  of  the  muscles  of  dcghilif  ion  and  of" 
respiration.  In  the  majority  of  cases  recovery  occurs  with  more  or  less  daniMge 
to  muscles  and  consequent  defects  of  motion. 

The  treatment  may  !)(■  Hiat  of  chronic  myelitis,  widi  the  siipcraddition 
of  local  electrical  treatment  l"or  the  nmiiilciiniicc  of  niilrilion  to  the  muscles, 
as  in  the  acute  disorder.     The  results  which  I  have  obtained  in  metallic  |)olio- 


772  ORGANIC  DISEASES    OF    THE  SPINAL    CORD. 

myelitis  (next  paragrapli)  would  seem  to  quite  justify  the  trial  of  heroic  doses 
of  strychnine. 

Atrophic  paralysis,  produced  by  arsenic  or  lead,  sometimes  closely  simulates 
subacute  poliomyelitis.  Probably  in  the  majority  of  cases  it  is  the  outcome  of 
a  peripheral  neuritis,  when  its  nature  is  to  be  recognized  by  the  existence  of 
nerve-pains  and  tenderness.  I  have,  however,  seen  cases  lacking  in  such  ten- 
derness, in  which  rapid  loss  of  power,  with  atrophy  and  atrophic  changes  in 
the  muscles,  occurred  without  pain  or  nerve-tenderness,  precisely  as  in  subacute 
poliomyelitis,  and  in  Avhich  I  believe  the  lesion  was  purely  centric. 

The  true  nature  of  metallic  subacute  poliomyelitis  can  usually  be  made 
out  by  attending  to  the  following  points:  first,  the  case  occurs  in  an  adult; 
second,  the  paralysis  is  much  more  widespread  than  in  the  subacute  or  mild 
cases  of  poliomyelitis,  and  develops  itself  to  the  fullest  extent  only  after  some 
weeks ;  third,  muscles  not  usually  affected  in  true  poliomyelitis  are  impaired 
almost  as  much  as  their  fellows  (thus  the  sphincters  are  paralyzed,  the  bladder 
rapidly  loses  power,  and  the  respiratory  muscles  grow  weak) ;  fourth,  sensa- 
tion is  often,  but  not  always,  affected  to  some  extent ;  fifth,  suspicion  being 
aroused,  evidences  of  metallic  poisoning  can  be  obtained  from  the  history,  from 
the  presence  of  a  blue  line  on  the  gums,  or  by  finding  the  metal  in  the  urine. 
The  treatment  of  this  condition  is  that  of  metallic  poisoning,  added  to  the  local 
use  of  electricity  upon  the  muscles  and  the  employment  of  massive  doses  of 
strychnine ;  which  alkaloid  I  have  seen,  when  pushed  to  its  physiological 
limit,  act  with  almost  as  much  force  and  certainty  as  does  quinine  in  malarial 
diseases. 

Syringomyelia. 

Definition. — A  chronic  disease  dependent  upon  the  formation  of  pathological 
cavities  in  the  spinal  cord,  and  clinically  characterized  by  peculiar  alterations  in 
the  sensibility,  and  loss  of  power  usually  accompanied  by  trophic  disturbances. 

Etiolog-y. — Concerning  the  causes  of  syringomyelia  we  have  no  definite 
knowledge.  The  disease  usually  begins  between  fifteen  and  thirty -five  years 
of  age;  is  more  frequent  in  men  than  in  women;  and  does  not  appear  to  be 
distinctly  hereditary,  although  there  is  some  reason  for  believing  that  it 
depends  upon  some  embryological  affection  of  the  cord  which  diminishes  the 
power  of  the  nerve-elements  to  resist  the  hyperplastic  tendency  inherent  in 
neurogliar  tissues. 

Patholog-y. — The  principal  lesion  in  syringomyelia  is  spinal,  with  secondary 
trophic  lesions  in  muscles,  bones,  cellular  tissues,  skin,  and  probably  also  in 
the  peripheral  nerves.  To  macroscopic  examination  the  cord  presents  the 
appearance  of  a  large  blood-vessel  empty  and  collapsed.  It  is  irregularly 
increased  in  size,  deformed,  soft  and  fluctuating  to  the  touch,  or  feeling  like  a 
hard,  firm,  rigid  cord,  as  the  case  may  be.  Section  reveals  a  cavity,  or  more 
rarely  two  or  even  three  cavities,  situated  in  the  horns  of  the  gray  matter. 
The  size  of  tiie  cavity  and  its  length  vary  indefinitely,  and  its  shape  and 
cross  dimensions  also  vary  not  only  in  different  individuals,  but  in  different 


SYRIXGOMYELIA.  773 

parts  of  the  same  cord.  Its  contents  are  liquid  or  gelatinous,  and  even  to  the 
naked  eye  it  is  surrounded  by  a  smooth,  yellowish  membranous  coating. 

The  majority  of  investigators  believe  that  the  j)rimary  histological  lesion 
of  syringomyelia  is  a  neoplastic  hyperplasia  of  the  neuroglia  of  the  gray  matter, 
but  others  insist  that  it  is  a  hyperplastic  myelitis.  The  new  tissue  is  vellowish- 
brown,  and  usually  composed  of  one  or  two  nucleated,  spider-like  cells,  heaped 
together  and  anastomosing  with  one  another  by  their  nervous  branch-like  pro- 
cesses. In  the  interspaces  thus  made  are  granular  elements,  pigment-granules, 
and  small,  illy-defined,  yellow  retractile  bodies  of  doubtful  character.  The 
limiting  layer  lining  the  whole  of  the  cavity  is  a  dense,  fibrillary  felting, 
which  is  not  sclerotic,  but  has  probably  been  formed  from  prolongations  of  the 
cell-process.  The  parts  around  the  new  growth  are  compressed  and  irritated, 
and  so  secondary  inflammation,  hemorrhage,  and  widespread  sclerotic  degen- 
eration are  set  up.  The  peripheral  nerves  have  been  in  various  cases  found 
altered,  enlarged,  with  parenchymatous  and  interstitial  neuritis,  or  finally 
atrophied.  In  a  very  careful  study  of  Dejerine  it  was  found  that  the  intra- 
muscular nerves  were  normal  or  atrophic  according  as  their  muscles  were 
normal  or  atrophic,  indicating  that  the  changes  in  the  nerves  are  secondary 
and  trophic,  and  not  primary  lesions. 

Symptomatolog-y. — Syringomyelia  commences  insidiously,  with  weakness 
and  some  disorder  of  sensation  in  the  upper  extremities,  fi)llowed  after  a  time 
by  muscular  atrophy,  with  increase  in  the  sensory  disorders;  then  by  sjiinal 
curvature  in  the  form  of  scoliosis ;  and  finally  development  of  motor  palsy  in 
the  lower  limbs.  Vaso-motor  and  trophic  changes  in  the  skin,  subcutaneous 
cellular  tissues,  and  perhaps  in  the  joints  and  bones,  soon  follow  the  apj)ear- 
ance  of  the  muscular  atrophy. 

The  symptoms  of  syringomyelia  are  best  discussed  in  detail  by  an  analysis 
of  the  individual  groups  : 

Sensibility. — The  disturbances  of  sensation  are  the  most  characteristic  of 
any  of  the  symptoms.  The  ordinary  sensations  are  disassociated,  so  that 
whilst  sensibility  to  touch,  the  muscular  senses,  and  the  special  senses  remain 
])erfect,  the  sense  of  pain  and  the  power  of  recognizing  heat  and  cold  are  more 
or  less  completely  lost.  In  some  rare  instances  the  general  rule  is  deviated 
from,  either  in  the  ]>reservation  of  some  form  of  sensibility  commonly  lost,  or 
more  frequently  in  the  depression  of  some  of  the  sensibilities  commonly  pre- 
served. Cases  are  on  record  in  which  pain  and  thermic  sensibility  have  been 
increased  ;  further,  thermic  sense  perversions  may  exist,  so  that  hot  bodies  feel 
cold  and  cold  bo(li(>s  hot. 

The  degree  of  the  thermic  anaesthesia  varies  from  the  sim|)l('  inability  to 
note  slight  differences  of  temperature  uj)  to  such  complete  loss  that  a  |)atient 
may  be  burned  without  being  aware  of  it.  The  loss  of  (he  power  of  recog- 
nizing heat  does  not  ne(tessarily  coincide  in  degree  or  ])osition  wilh  ihc  loss 
of  the  perception  of  cold.  The  distribution  of  the  thcnno-aiia'sthcsia  varies  in 
different  cases,  and  to  a  limited  degn^e  fidin  time  (o  tiiiir  in  the  sam<'  case. 
It  usually  occuj)ies  considerable  zones — sometimes  nearly  ihc  whole  surface  of 


774  ORGANIC  DISEASES    OF    THE   SPINAL    CORD. 

the  body,  and  even  the  mucous  membranes,  as  well  as  the  skin.  Analgesia 
varies  in  intensity  and  in  distribution,  precisely  as  does  the  thermo-anaesthesia. 
In  spite  of  complete  analgesia  and  thermo-ansesthesia  the  slightest  prick  will 
be  recognized  by  the  tactile  sense,  wliilst  the  eye,  the  nose,  the  mouth  normally 
perform  their  seeing,  smelling,  and  tasting  functions.  In  some  cases  the  patient 
complains  of  subjective  pains  which  may  mock  the  sensations  of  burning  or 
of  freezing. 

As  already  stated,  loss  of  motor  power  in  the  arms  is  a  common  primary 
symptom.  In  the  legs  the  disturbances  of  motion,  which  are  usually  secondary 
and  develop  late  in  tiie  disorder,  commonly  consist  of  spasmodic  paraplegia, 
but  sometimes  are  especially  shown  in  marked  ataxic  inco-ordination.  Fol- 
lowing one  or  other  of  these,  the  patellar  reflexes  may  be  either  exaggerated  or 
abolished.  Loss  of  motion  is  followed  in  tlie  upper  extremities  by  muscular 
atrophy  and  secondary  contractures,  with  the  production  of  claw-like  deformi- 
ties like  those  of  progressive  muscular  atrophy.  The  muscles  of  the  back 
suffer  paralysis  and  trophic  disturbance  almost  as  soon  as  do  the  muscles  of 
the  upper  extremities,  and  therefore  scoliosis  is  an  almost  constant  and  some- 
times an  early  symptom.  It  is  said  almost  universally  to  affect  the  dorso- 
liunbar  region  and  to  produce  convexity  to  the  left. 

The  atrophy  which  first  appears  in  the  muscles  of  the  forearm  usually 
extends  slowly  and  symmetrically  up  the  arm,  and  is  sometimes  accompanied  by 
the  reaction  of  degeneration,  although  usually  tiie  electrical  excitability  is  only 
diminished.  It  should  be  noted  that  both  paralysis  and  atrophy  may  first 
appear  in  the  scapular  region,  or  even  in  the  lower  extremities,  and  that  a  few 
cases  of  facial  paralysis  with  atrophy  have  been  reported. 

The  superficial  trophic  changes  are  very  marked.  The  skin  may  become 
glossy  or  covered  with  a  thick  epidermis  or  with  bullous,  eczematous,  or  her- 
petic eruptions.  Perforating  ulcers  have  been  described,  and  in  rare  cases 
there  has  been  a  primitive  gangrene  of  the  skin,  followed  by  loss  of  sub- 
stance and  leaving  a  whitish  cicatrix.  Tiie  distorted,  thickened,  often  fur- 
rowed nails  sometimes  fall  out.  The  subcutaneous  cellular  tissues  may  be 
oedematous  or  the  seat  of  abscesses  and  especially  of  whitlows.  The  bones  and 
joints  sometimes  undergo  arthropathic  changes  similar  to  those  seen  in  loco- 
UKjtor  ataxia  ;  and  acromegalia,  coinciding  with,  if  not  dependent  upon,  syringo- 
myelia, has  been  reported. 

The  secreting  nerves  seem  to  suffer;  at  least  sweating  becomes  irregular, 
absent  in  some  regions,  or  it  may  be  exaggerated.  The  vaso-motor  system 
is  also  atta(^kcd,  the  extremities  cyanosed,  with  their  temperature  distinctly 
below  tlu"  norm,  or  else  they  become  swollen,  scarlet,  and  hot.  Polyuria  has 
also  been  noted.  Sometimes  cystitis  is  severe,  and  perforating  ulcer  of  tiie 
bladder  has  been  reported. 

The  general  type  of  syringomyelia  is  departed  from  when  the  lesion  is 
atypically  located.  Thus,  bulbar  paralysis,  with  disturbance  of  deglutition 
and  of  speech,  may  occur  when  the  change  is  very  high  up  in  the  nervous 
system,      .\maiirosis,  unequal  ]iupils,  cardiac  disturbances,  all  have  been  noted. 


SYlilXaOMYELTA .  775 

More  strangely,  the  characteristic  lesions  of  syringomyelia  have  been  found 
after  death  in  cases  where  no  symptoms  have  been  nuinilcstcd  during  life. 
The  only  plausible  explanation  of  this  is  that  offered  by  M.  Bruhl,  which  is 
that  these  latent  tonus  occur  only  in  young  patients  in  whom  there  has  not 
been   time  for  develojiment  of  symptoms. 

Two  clinical  varieties  of  the  disease  are  described  by  Blocq.  In  the  first 
of  these  the  atrophy  commences  in  the  muscles  supplied  by  the  ulnar  nerve, 
and  is  followed  by  si)astic  paraplegia ;  in  the  other  the  atrophy  conmiences  in 
the  muscles  of  the  radial  nerve,  and  is  followed  by  tabetic  iuco-ordination.  The 
course  of  syringomyelia  is  a  prolonged  one,  disturbed  often  by  exacerbations 
and  remissions.  If  the  patient  do  not  die  of  some  intercurrent  disease,  death 
results  from  some  of,  the  trophic  lesions  (gangrene,  cystitis,  perforating  ulcer), 
from  bulbar  com])lications,  or  occasionally  from  sheer  exhaustion. 

Diagnosis. — Syringomyelia  is  distinguished  from  cervical  pachymeningitis 
by  being  much  less  painful  and  not  accompanied  by  rigidity  of  the  neck,  and 
by  the  existence  of  the  peculiar  disturbances  of  sensation.  In  cases  of  sclero- 
dactylitis,  simulating  syringomyelia,  sensation  is  preserved,  whilst  the  inflam- 
mation of  the  skin  is  a  dominant,  not  a  secondary,  feature  of  the  case.  In 
alcoholic  paralysis  thermo-anassthetic  disturbances  resembling  those  of  syringo- 
myelia sometimes  occur,  but  the  symptoms  usually  appear  in  the  lower  extrem- 
ities and  are  developed  very  rapidly,  whilst  tenderness  of  the  nniscles  or  nerve- 
trunks  upon  deep  pressure  can  be  made  out.  Charcot  has  pointed  out  that 
hvsteria  mav  closely  mark  syringomyelia,  but  an  error  of  diagnosis  can  always 
be  avoided  by  carefully  examining  the  patient  and  her  or  his  history.  Hys- 
teria is  rapid  in  its  onset,  and  manifests  its  presence  by  nervous  symptoms  not 
belonging  to  syringomyelia. 

The  question  as  to  the  distinctness  of  Morvan's  disease  is  still  sub  judice : 
those  who  believe  in  the  non-identity  make  the  diagnosis  to  depend  u})ou  the 
following  points  : 

In  Morvan's  disease  the  tactile  sense  nearly  always  disappears  with  the 
other  forms  of  sensibility  ;  the  trophic  changes  predominate,  and  almost  exclu- 
sively consist  of  multiple  whitlows,  deep  cracks  and  fissures  in  the  skin,  and 
arthropathies  of  the  smaller  joints.  Moreover,  in  certain  cases  these  affections 
are  symmetrical  on  both  hands  and  feet  and  do  not  attack  the  remnin<ler  of  the 
body.  Finally,  the  muscular  atrophy  is  slightly  marked,  and  is  nut,  as  a  rnlc, 
progressive. 

Prognosis. — The  prognosis  of  syringomyelia  is  exceedingly  serious,  although 
it  has  been  aflirmed  that  recovery  is  possible,  and  life  may  certainly  be  much 
j)rolongcd. 

Treatment. — Counter-irritation  by  means  of  the  actual  cautery  and  siis- 
■nsion,  as  in  the  treatment  of  locomotor  ataxia,  are  reeoin mended  bv  I'^reneh 


I» 


authors.  There  seems  no  probability  that  any  drugs  have  direcl  inlluence 
upon  the  disease,  but  of  course;  syniptoins  uiu.-(  be  met  as  they  arise  and 
defective  nutrition  eoiubafed.  Elec-tricity  may  l)e  eni])l(»yed  for  the  prevention 
of  muscular  ati-oj)h\'.      Tlie  most  irupoi-fMut  indications  are  Ibr  earelul  hygienic; 


776  ORGANIC  DISEASES    OF    THE  SPINAL    CORD. 

and  mediciual   management  to  protect  from  injury  the  analgesic  skin  and  to 
prevent  muscular  fatigue  or  cystic  complications. 

Locomotor  Ataxia. 

Definition. — A  disease  of  which  the  lesion  is  sclerosis  of  the  posterior  root- 
zones  of  the  spinal  cord,  and  in  which  the  symptoms  are  vertigo,  disturbance 
of  the  movements  of  the  eyeballs,  Argyll-Robertson  pupil,  contraction  of  the 
field  of  vision,  pain  or  other  disturbance  of  sensation,  loss  of  the  knee-jerk, 
loss  of  co-ordination,  without  true  paralysis  or  spasm. 

Synonyms. — Posterior  spinal  sclerosis  ;  Tabes  dorsalis ;  Duchenne's  dis- 
ease. 

Patholog-y. — The  general  structural  changes  of  posterior  sclerosis  are  very 
evident,  and  its  patliological  histology  well  determined,  although  our  know- 
ledge of  the  true  nature  and  of  the  development  of  the  lesions  is  imperfect 
and  the  theory  of  the  disease  still  somewhat  speculative.  When  in  the  typ- 
ical case  the  spinal  cord  is  examined  macroscopically  by  means  of  repeated  sec- 
tions, the  structural  alteration  is  seen  to  be  most  intense  and  widespread  in  the 
lumbar  region  of  the  cord,  whilst  the  posterior  columns  appear  to  be  replaced 
by  a  gray,  almost  gelatinous-looking,  substance  (gray  degeneration).  VYhen 
the  cord  has  been  hardened  in  chromic-acid  solution  the  difference  between  the 
sound  and  diseased  tissue  is  very  marked,  and  it  usually  can  be  readily  made 
out  that  the  tract  of  degenerative  tissue  continually  narrows  from  below 
upward  by  a  loss  of  its  lateral  or  external  portions,  so  that  at  last  it  becomes 
a  narrow  band  or  column  (in  section  a  zone)  upon  each  side  of  the  posterior 
spinal  fissure.  This  arrangement  of  the  degeneration  is  not,  however  uni- 
versal, and  the  upper  portion  of  the  cord,  or  even  the  medulla,  may  be 
primarily  and  most  severely  involved. 

The  sclerotic  process  usually  begins  in  that  portion  of  the  posterior  column 
through  which  the  posterior  routs  of  the  spinal  nerve  run,  and  to  which  the 
name  of  the  "  posterior  root-zones  "  has  been  given.  This  portion  of  the  spinal 
cord  has  in  it  ascending  nerve-bundles,  which  in  their  passage  upward  escape 
into  the  slender  columns  in  immediate  juxtaposition  to  the  posterior  fissure 
(columns  of  Goll).  In  travelling  up  the  cord  the  degenerative  process  extends 
along  the  root-zones  and  along  the  columns  of  Goll.  In  some  cases  the 
columns  of  Goll  seem  to  bear  the  brunt  of  the  disease,  in  others  the  root- 
zones  are  especially  affected. 

Microscopic  examination  of  those  portions  of  the  cord  where  the  patholog- 
ical process  has  reached  its  farthest  limit  reveals  a  mass  of  connective  tissue, 
with  scattered  through  it  here  and  there  minute  points,  the  atrophied  axis- 
cylinders  from  which  the  myeline  sheaths  have  wasted  away.  The  connective 
tissue  is  fibrillated  and  nucleated,  with  excessive  trabeculse.  The  blood-vessels 
also  have  undergone  a  marked  sclerotic  change,  which  especially  affects  the 
outer  coats  and  adventitial  sheaths,  and  lessens  the  lumen  of  the  vessels. 
When  the  sclerosis  is  less  advanced,  the  change  consists  in  an  increase  in 
the   nuclei   and   the   mass  of  the  connective  tissue,  accompanied  by  wasting 


LOro^TOTOU    ATAXIA.  777 

of  the  myeline  sheaths,  and,  it  luay  be,  a  (ii.^appearanee  of  some  of  the  axis- 
cylinders. 

The  exact  beginning  of  the  sclerotic  process  has  not  yet  been  positively 
determined,  but  the  view  of  Westphal  that  there  is  a  stage  of  granular  change 
preceding  that  of  pronounced  sclerosis  is  received  with  favor  by  most  jiatholo- 
gists.  On  the  other  hand,  pathologists  are  divided  in  regard  to  the  question 
whether  the  lesion  of  locomotor  ataxia  comraencas  in  the  connective  tissue  or 
in  the  nerve-elements ;  some  maintaining  that  the  disease  is  originally  inter- 
stitial, and  that  the  nerve-elements  are  wasted  by  the  pressure  exerted  upon 
them  by  the  hyperplastic  neuroglia,  whilst  others  teach  that  the  disease  is 
parenchymatous — i.  e.  that  the  original  change  occurs  in  the  nerve-filaments, 
and  that  the  connective-tissue  hy})eri)lasia  is  a  secondary  result.  Some,  nota- 
bly Spitzka,  go  so  far  as  to  believe  that  there  are  two  varieties  of  locomotor 
ataxia :  one  parenchymatous,  one  interstitial — a  view  which  seems  to  me 
highly   improbable. 

As  was  first  pointed  out  by  Westphal,  the  peripheral  nerves  frequently 
suffer  in  tabes,  the  degeneration  beginning  in  the  white  matter  and  ultimately 
spreading  to  the  axis-cylinders,  and  being  accompanied  by  an  increase  of 
connective  tissue.  The  sensory  filaments  appear  to  suffer  alone.  That  the 
degeneration  is  not  due  to  propagation  by  contiguity  of  the  spinal  lesion  is 
shown  by  the  fact  that  the  change  begins  in  the  cutaneous  filaments  and  leaves 
the  large  nerve-trunks  free.  Further,  the  degree  of  alteration  in  the  nerves 
bears  no  proportionate  relation  to  the  changes  in  the  spinal  cord.  There  is 
much  reason  for  believing  that  in  some  cases  of  tabes  the  chano;e  in  the  nerves 
precedes  the  change  in  the  cord,  and  that  both  alterations  are  the  result  of  a 
common  cause. 

Atrophy  of  the  optic,  pneumogastric,  trigeminus,  and  other  cephalic  nerves, 
with  great  wasting  of  fibres  and  hyperplasia  of  connective  tissue,  and  even 
involvement  of  the  central  ganglia,  are  occasionally  found. 

The  gray  matter  of  the  cord  is  unaffected  save  in  very  advanced  cases, 
when  the  columns  of  Clarke  show  atrophy  of  their  fine  nerve-fibres,  and  in  some 
cases  wasting  of  their  cells.  When  there  has  been  during  life  widespread  nuis- 
cular  atrophy  there  is  corresponding  atrophy  of  the  spinal  cells. 

Etiolog-y. — Locomotor  ataxia  is  not  hereditary  ;  is  much  more  fre([uent  in 
males  than  in  females;  is  a  disease  of  middle  life,  although  it  may  occur  at 
any  ajre.  The  causes  in  individual  cases  are  nsuallv  verv  obscure.  Tn  a  lartre 
majority  of  eases  there  is  a  past  history  of  syphilitic  infection,  but  tiic  disease 
is  not,  strictly  speaking,  syphilitic,  and  is  not  relieved  by  antisy]>hilitic  treat- 
ment. Professor  Striitnpel's  theory  that  it  occurs  only  in  the  sy|)hilitic,  and  is 
])r<»duced  by  a  ])ost-syphilitic  chemical  poison,  is  iiighly  improbable.  The  old 
belief  that  sexual  excess  is  the  ordinary  cause  of  locomotor  ataxia  is  certainly 
not  true,  though  such  excess  may  ai<l  in  its  development.  Over-work,  nervdus 
strain,  worry,  emotional  excitement,  th(;  immoderate  use  of  alcohol  and  tobacco, 
liave  been  assigned  as  causes,  but  thcii-  inlbn'iicc  is  very  obscure.  Habitual  or 
even  single  iniaccustomed  ex[)osure  to  wet  and  cold,  especially  when  conibiMcd 


778  ORGANIC  DISEASES    OF    THE  SPINAL    CORD. 

with  exhausting  labor,  a|)pGars  to  have  had  distinct  influence  in  some  cases. 
Peripheral  traumatisms  seem  at  times  to  produce  tabes,  probably  by  causing 
an  ascending  nerve-degeneration.^  How  far  lead  and  otlier  poisons  act  is 
uncertain,  but  Tuczek  has  described  under  the  name  of  tabes  ergotica  an 
affection  closely  simulating  locomotor  ataxia.  It  is  probable  that  in  the 
majority  of  cases  various  causes  work  together  for  the  one  result.  Syphilis, 
venereal  and  alcoholic  excesses,  worry,  mental  strain,  over-exertion,  and  undue 
exposure  are  often  coincident  factors  in  the  life  of  one  individual. 

Symptomatology. — The  development  of  locomotor  ataxia  is  usually  very 
slow,  insidious,  and  without  fixed  regularity  in  the  relative  development  of 
symptoms.  Usually  the  first  manifestations  are  in  the  legs,  but  sometimes 
double  vision,  giddiness,  or  pains  about  the  head  take  precedence,  and  the 
affection  may  for  years  be  seated  almost  exclusively  in  the  upper  extremities. 
This  is  evidently  due  to  the  fact  that  although  usually  the  pathological 
changes  begin  in  the  lower  portions  of  the  spinal  cord  and  work  upward, 
sometimes  they  pass  from  above  downward.  The  nature  of  the  symptoms  of 
the  earlier  stages  will  be  discussed  under  Diagnosis.  The  general  symptoms 
can  be  best  studied  in  a  brief  space  under  the  headings  of  the  functions 
involved  : 

First :  Disturbances  of  sensation  ; 

Second  :   Disturbances  of  motion  ; 

Third  :   Disorder  of  the  organs  of  the  special  senses  ; 

Fourth  :  Trophic  changes. 

DlMurbanees  of  Sensation. — Pain  is  present  in  nine-tenths  of  the  cases  of 
tabes.  It  is  variously  described  by  the  sufferers  as  shooting,  darting,  as  a  feel- 
ing as  though  lightning  were  running  through  the  part  or  as  though  a  red-hot 
wire  or  a  sharn  dagger  were  thrust  through  the  limb.  In  some  cases  these  so- 
called  fulgurant  pains  occur  continually  ;  in  other  instances  they  come  on  in 
paroxysms ;  but  almost  invariably  they  temporarily  disappear  at  intervals. 
They  may  follow  the  distribution  of  the  nerves,  but  more  commonly  are  felt 
most  severely  in  the  neighborhood  of  the  joints,  especially  in  the  inside  or  the 
outside  of  the  knee  or  of  the  ankle.  Usually  they  are  not  associated  with 
redness  or  any  soreness,  and  often  the  patient  seizes  the  affected  part  forcibly 
and  obtains  by  the  pressure  some  relief.  A  certain  amount  of  redness  and 
tenderness  may,  however,  be  present  during  the  pain,  and  in  exceedingly  rare 
cases  trophic  eruptions  occur.  Sometimes  the  pain  seems  widespread  and 
superficial,  and  is  then  usually  spoken  of  as  burning  or  more  rarely  as  a  sen- 
sation of  intense  cold. 

Fain  crises,  which  are  almost  pathognomonic  of  locomotor  ataxia,  consist 
of  paroxysms  of  excessive  ])ain  without  fever,  located  in  some  viscus  or 
organ,  and  accompanied  by  excessive  functional  disorder  of  the  part.  They 
frequently  cf)me  on  and  disappear  with  great  ra])idity  and  abruptness,  and 
may  last  from  a  few  minutes  to  several  days.  When  the  agony  is  su])reme 
syncope  may  bring  relief,  or  there  may  occur  a  wild  outburst  of  maniacal  mel- 

'  See  Klemperer,  Tftesi^,  Berlin,  1889. 


LOCOMOTOR    ATAXIA.  770 

ancholy  with  attempts  at  suicide.  Tlie  paralyzed  functional  activity  is  usually 
recovered  with  remarkable  rapidity  when  the  paroxysm  ends.  The  most 
important  of  the  pain  crises  are  the  muscular,  the  gastric,  the  rectal,  the 
urinary,  the  genital,  the  cardiac,  and  the  laryngeal. 

The  muscular  crises,  which  are  extremely  rare,  consist  of  a  feeling  of  las- 
situdc,  deepening  into  an  excessive  muscular  weariness  and  soreness  (like  that 
which  follows  violent  exercise  in  one  unaccustomed  to  it),  and  at  last  entirely 
paralyzing,  for  the  time  being,  the  affected  muscles. 

The  gastric  crises,  the  most  frequent  of  any,  are  characterized  by  violent 
shooting  and  burning  pains,  having  their  focus  in  the  c})igastric  region  and 
radiating  in  all  directions,  laterally,  upward,  downward,  until  at  times  they 
seem  to  fill  with  agony  the  whole  abdomen  and  chest.  They  arc  generally 
increased  by  epigastric  pressure  and  by  the  ingestion  of  food,  and  are  always 
accompanied  by  nausea  and  excessive  vomiting.  After  the  stomach  has  been 
once  emptied  the  discharge  is  glairy  or  ropy,  neutral  or  acid,  and  often 
streaked  with  blood  ;  rarely  there  is  abundant  coffee-":round  vomitincr  or  even 
pronounced  htematemesis.  In  some  cases  the  focus  of  the  pain  is  in  the 
neighborhood  of  the  umbilicus,  when  the  crises  might  pro})erly  be  spoken  of 
as  intesiinal.  Occasionally  large  quantities  of  gas  form  in  the  gastro-intes- 
tinal  tract  and  produce  a  very  obstinate  meteorism,  or  there  may  be  copious 
bilious,  mucous,  or  serous  stools.  In  such  cases  loss  of  the  voice,  suppression 
of  urine,  extreme  coldness  and  cyanosis  of  the  body,  cramps,  and  collapse  may 
closely  simulate  cholera,  and  death  may  result. 

In  the  rectal  crises  the  pains  radiate  from  the  rectum,  or  this  receptacle 
feels  as  though  it  were  filled  up  by  an  enormous  body  heated  to  redness,  burn- 
ing and  scorching  every  part  near  it. 

The  genital  crises  are  of  two  characters.  In  one,  violent  ])aroxysras  of 
])ain  centre  in  the  testicles  and  shoot  along  the  penis  to  its  head,  or  in  the 
female  burn  and  bore  in  the  ovaries,  the  labia  minora,  and  the  clitoris.  In 
other  cases  frequent  spontaneous  venereal  orgasms  replace  the  pain-paroxysms. 
At  first  the  paroxysms  end  in  a  fury  of  voluptuous  delight,  but  more  and 
more  pain  tramples  over  pleasure  until  at  last  the  orgasm  is  but  luispeakable 
torture. 

The  genito-urinary  crises  may  simulate  renal  colic,  the  pain  radiating  along 
the  ureters  into  the  genitalia  and  being  associated  with  retraction  of  the  testicles. 
More  frequently,  however,  intense  burning  or  lancinating  darts  of  agony  in  the 
urethra,  associated  with  unconquerable  cystic  tenesmus,  suggest  the  presence 
of  calculi — a  suggestion  wiiich  is  especially  forcible  in  those  cases  in  which  the 
pain  is  persistent  and  auicsthesia  of  the  bladder  gives  rise  to  urinary  retention 
and  anmioniacal  fermentation,  with  subsequent  de])osits  of  phosphates. 

The  symptoms  of  the  cardiac  crises  are  violent  Innciuatiug  and  constricting 
]>ains  in  the  region  of  the  heart,  associntcd  with  great  dyspntea,  intense  dis- 
tress, and  irregularity  of  the  jmlse,  witii  or  without  iutciniissioii  of  the  heart- 
beats. 

The  lart/ngeal  crises  consist  of  violent  paroxysms  of  hoarse  coughing,  ending 


780  ORGANIC  DISEASES    OF   THE  SPINAL    CORD. 

ill  a  raucous  inspiration  like  that  of  whooping  cough,  and  attended  by  great  lar- 
yngeal disturbances  of  respiration  and  atrocious  fulgurant  pains  in  the  shoul- 
ders and  along  the  spinal  column.  The  expectoration  is  of  a  scanty,  saliva-like 
secretion,  or  rarely  of  little  pellets  of  mucus  stained  with  blood.  Asphyxia 
may  in  these  cases  be  so  extreme  as  to  produce  coma  and  even  death.  In  some 
eases  laryngeal  paralysis  or  anaesthesia  occurs,  and  death  has  resulted  from  the 
pneumonia  produced  by  food  i)assing  into  the  larynx. 

Amongst  the  various  parsesthesias  of  locomotor  ataxia  are  formications,  the 
feeling  that  water  is  running  over  the  part,  crawling  of  ants,  etc.,  and  espe- 
cially the  so-called  girdle  sensation,  a  feeling  as  though  a  tight  band  was 
drawn  around  the  head,  the  neck,  the  body,  or  the  limbs,  in  accordance  with 
the  seat  of  the  lesion  in  the  cord.  Numbness  may  develop  early  or  late. 
When  it  is  situated  in  the  feet  the  patient  feels  as  though  he  were  walking 
upon  velvet  or  upon  cushions  of  down.  The  mucous  membrane  of  organs, 
such  as  the  larynx  and  rectum,  in  which  the  crises  occur  is  often  completely 
anaesthetic. 

In  the  earlier  stages  the  numbness  is  not  invariably  associated  with  loss  of 
sensibility,  and  the  jesthesiometrical  points  may  be  distinctly  recognized,  but 
later  tactile  sensation  becomes  impaired.  The  anaesthesia  may  exist  with  or 
without  analgesia,  although  the  pain  sensation  is  usually  also  lost.  Sometimes 
a  separation  occurs  between  tactile  and  pain  perception,  so  that  a  distinct  inter- 
val exists  between  the  perceiving  of  the  contact  of  a  sharp  point  and  the  pain 
which  it  causes.  The  temperature  sensation  is  usually  diminished,  but  Donath 
affirms  that  there  are  cases  in  which  it  is  exalted.  The  lack  of  co-ordination 
of  tabes  is,  I  believe,  largely  due  to  loss  of  muscular  sense,  but  as  physiolo- 
gists are  not  all  agreed  even  as  to  the  existence  of  this  sense,  the  discussion 
Avould  require  more  space  than  can  be  afforded  here.  Delayed  sensation  is  not 
uncommon,  and  five,  ten,  or  even  fifteen  seconds  may  elapse  between  the  time 
of  the  contact  and  its  perception.  Mendelssohn  affirms  that  the  normal  reac- 
tion of  the  sensory  nerve  to  electricity  may  be  reversed,  so  that  on  closing  of 
the  circuit  the  earliest  sensation  is  at  the  positive  instead  of  at  the  negative 
pole,  as  in  health.  The  localizing  power  is  sometimes  curiously  perverted  :  a 
single  prick  may  be  felt  in  many  places  (polycesthesia),  or  a  prick  on  one  leg 
may  be  located  on  the  other  (allocheiria). 

3Iotion,  including  the  Reflexes. — The  influence  of  locomotor  ataxia  upon 
the  cutaneous  reflexes  varies.  In  the  onset  of  the  case  they  are,  in  rare 
instances,  increased;  when  anaesthesia  exists  they  are  usually  diminished;  but 
sensation  may  be  well  preserved  and  the  cutaneous  reflexes  be  lessened  or  even 
abolished.  The  deeper  reflexes  are  profoundly  affected.  Complete  loss  of  the 
knee-jerk  {Westphal's  symjytom)  is  one  of  the  earliest  and  most  constant  phe- 
nomena. When,  however,  the  disease  commences  in  the  upper  portion  of  the 
cord,  it  mav  be  late  in  comino-  on. 

Loss  of  co-ordination  shows  itself  both  in  station  and  in  locomotion. 
When  it  exists  only  in  a  slight  degree,  the  patient  may  be  able  to  stand  with 
the  feet  close  together  or  on  one  foot,  or  may  be  able  to  walk  fairly  well ; 


LOCOMOTOR   ATAXIA.  781 

but  if  the  eyes  he  closed,  the   lack  of  control  becomes  at  once  manifest,  and 
as  the  disease  develops  a  gait  so  peculiar  as  to  be  spoken  of  as  the  ataxic 
(/ait    results.      In  the  earlier,   but   fully-developed    stages  the  })atient  walUs 
with  his  head  a   little    bent  forward   and    the  eyes  directed  to  the   ground. 
The  trunk  inclines    upon   the    thighs,   whilst  the  feet  are    held    in    advance 
of  the  buttocks,   with  the  legs  widely  separated  from  each   other.     At    the 
same  time,  owing    to    the   excessive   contractions  of  all   the  muscles  of  the 
lower  extremities,  the    leg   proper  is  extended    somewhat    rigidly  uj^on    the 
thigh,  and  there  is  very  little  movement  at  the  knee-joint.     The  advancing 
leg    is  therefore  raised  from    the    ground    in   some   degree    by  an    elevation 
of  the    pelvis,  although    at  the   same  time   some  flexion    does  occur    at    the 
knee-joint.     By  these  conjoint  movements  the  foot  is  freed  from  the  ground, 
and,  having  been  flung  forward  and  outward  by  a  rapid  muscular  jerk,  comes 
down  with  a  thump  like  a  solid  mass.     In  some  cases  the  heel  is  the  Jast  to 
leave  the  ground  and  the  first  to  touch  it.     Not  rarely  the  pelvis  is  so  much 
inclined  during  walking  as  to  carry  the  centre  of  gravity  too  fjir  toward  the 
side  of  the  stationary  leg.     To  counteract  this  and  maintain  the  balance  of  the 
body  the  upi)er  portion  of  the  trunk  is  curved  toward  the  advancing  leg  by  a 
contraction  of  the  erector  spinae   muscles,  or  the  arm   corresponding  to  the 
advancing  leg  is  thrust  out  laterally.     The  alternation  of  these  movements  at 
each  step  may  give  a  pendulum-like  swing  to  the  body.      In  a  more  advanced 
stage  of  locomotor  ataxia  the  patient  is  able  to  walk  oidy  by  the  help  of  two 
sticks  or  crutches.     The  body  is  thrown  forward  in  order  to  counteract  the 
tendency  to  fall  backward  produced  by  the  peculiar  position  assumed  by  the 
legs,  which  are  held  in  advance  of  the  buttock  on  account  of  the  tendency  to 
undue  contraction  of  their  extensor  muscles :  the  foot  is  usually  at  an  obtuse 
angle  to  the  leg,  and  the  thigh  at  an  obtuse  angle  to  the  trunk.      Jf  under 
these  circumstances  the  trunk  be  erect,  the  line  of  the  centre  of  gravity  would 
fall  through  the  buttocks  posterior  to  the  point  of  support — i.  e.  the  foot — and 
consequently  the  patient  would  fall  backward.     To  overcome  this,  the  trunk  is 
often  bent  so  far  forward  that  the  line  of  the  centre  of  <rravitv  is  in  front  of 
the  feet,  and  the  patient  would   fall  forward  if  he  were  not  supjxntcd   by  a 
stick  or  crutches.     All  the  movements  executed  with  the  legs  are  i>erformed 
with    great    stiffness    and   by   sudden  jerks.     The  straddle   is    usually   very 
marked,  and  the  leg  js  raised   from  the  ground  by  an  elevation  of  the  pelvis 
in  the  method   already  described.     Still    later   in    the   disorder  the   legs  are 
entirely  beyond  the  control  of  the  patient.     They  are  thrown  around  in  wild, 
irregular,  ehf)reiform   movements,   which   render  them   of  no  use  whatever  in 
walking.     Tinder  these  circumstances  j)rogression   is  inipossible.      When   the 
lesion  travels  up  the  spinal  cord,  all  power  of  co-ordinating  the  nuisch>s  of  the 
truid<  may  be  lost,  so  that  the  ])atient  is  net  longer  able  to  sit  in  a  chair. 

OrganH  of  l^pecinl  Sense. — Of  the  organs  of  s]>ecial  sense,  the  eye  is  the 
OIK!  most  fre(piently  attacked  in  Idconiotor  ataxia.  Of  the  external  oeidar 
nnisdes,  the  rectus  is  th<!  most  frequently  jcirnly/ed,  bnt  any  nin-ele  may  l>e 
affected.       The    loss    of    j»ower    inav    be    transient    or    |ierni:iMenl.       'i'ransient 


782  ORGANIC  DISEASES    OF    THE  SPINAL    CORD. 


s 


ocular  palsy,  with  its  resultant  transient  diplopia,  belongs  to  the  earliest  period 
of  the  disorder.  The  permanent  palsy  is  seen  in  the  later  stages,  and  may 
])roduce  ptosis,  internal  or  more  rarely  external  squint,  and  even  a  general 
ophthalmoplegia. 

The  pupil  is  affected  sooner  or  later  in  a  majority  of  oases  of  locomotor 
ataxia.  It  is  usually  contracted,  but  mydriasis  may  occur,  and  irregularity 
of  the  pupil  is  sometimes  seen.  The  most  characteristic  alteration  is  that 
known  as  the  Argyll- Robertson  pupil,  or  as  reflex  iridoplegia.  In  this  con- 
dition the  pupillary  reflexes  are  abolished,  although  the  normal  relatione 
between  the  pupil  and  accommodation  are  preserved  ;  consequently,  no  pupil- 
lary movement  occurs  when  the  skin  of  the  neck  is  violently  pinched  or 
when  light  is  thrown  suddenly  into  or  shut  off  from  the  disordered  eye, 
although  the  pupil  dilates  when  the  gaze  is  suddenly  directed  from  a  near 
to  a  distant  object. 

The  most  characteristic  visual  results  of  locomotor  ataxia  are  contractions 
of  the  field  of  vision,  with  disorder  of  the  color  sense.  The  contraction  is 
concentric,  but  is  usually  somewhat  irregular.  The  power  of  perceiving  yellow 
and  blue  is  kept  for  a  long  time,  whilst  blindness  for  green  or  red  is  early 
developed.  The  contraction  of  the  field  of  vision  and  the  disorder  of  the 
color  sense  are  due  to  degeneration  of  the  nerve-fibres  of  the  optic  nerve ; 
which  degeneration  usually  commences  in  the  periphery. 

I  know  of  no  observations  on  disorder  of  either  taste  or  smell  in  locomotor 
ataxia.  Deafness  occasionally  occurs  either  as  an  early  transient  or  a  late 
permanent  symptom.  According  to  Gowers,  it  is  accompanied  by  a  progressive 
limitation  of  the  range  of  hearing  analogous  to  the  contraction  of  the  range 
of  visual  field ;  the  notes  of  the  scale,  beginning  at  the  top,  dropping  out  of 
the  range  of  hearing,  one  after  the  other,  until  all  are  alike  inaudible. 

Trophic  Changes. — The  most  important  trophic  changes  in  locomotor  ataxia 
are  alterations  of  the  bones  and  joints,  perforating  ulcer,  and  })erhaps  cardiac 
disease.  Sclerotic  arthropathy  may  first  show  itself  by  a  peculiar  articular 
crepitus,  but  the  first  fully-formed  stage  is  that  in  which  a  serous  effusion,  free 
from  blood,  pus,  or  albuminous  flocculi,  occurs  in  the  articular  cavity,  whence 
it  may  extend  into  the  tissues  around  the  joint  and  even  into  the  affected  limb. 
The  joint  at  this  time  is  enormously  swollen,  hard,  usually  pale,  and  so  resistant 
as  not  to  pit  on  pressure.  In  rare  cases  the  effusion  is. absorbed,  but  usually 
the  second  stage  is  soon  developed.  At  this  time  the  joint  is  much  swollen, 
hard,  and  bony,  with  an  evident  increase  in  the  size  of  the  bony  surfaces.  In 
the  third  stage  there  is  destruction  of  the  articulating  surfaces,  and  in  some 
oases  so  much  absorption  of  the  bone  and  changes  in  the  ligamentous  structure 
as  to  produce  great  alterations  in  the  power  of  movement.  The  epiphyses 
espe(;ially  undergo  atro|)hy  and  ohange ;  the  ligaments  are  elongated,  probably 
as  a  consequence  of  prolonged  stretching  by  the  excess  of  fluid;  and  at  last  a 
condition  of  subluxation,  or  perhaps  of  complete  luxation,  of  the  joint  occurs, 
so  that  the  ataxic  may  be  able  voluntarily  to  ])nt  out  of  joint  a  shoulder,  a 
knee,  or  other  joint  without  pain,  though  marked  grating  can  be  felt  during 


L  O  CO  MO  TOR    A  T.  1  AT.  1 , 


783 


movement.  The  ataxic  arthropatliy  is  sometimes  unilateral,  but  is  frequently 
more  or  less  symmetrical.  It  attacks  especially  the  knees,  and  next  in  order 
of  frequency  the  other  joints  of  the  lower  extremities,  but  it  may  occur  in  any 
articulation  of  the  body.  When  the  small 
joints  of  the    hand   or   foot   are    affected, 

peculiar   deformations    result,    constituting 

r 

Fig.  52. 


Fk;. 


Tabetic  Feet  (after  nature). 


-       ^ 

U    y 

Impression  of  Tabelic  IV-ct  lafter  Hall). 


Fig.  54. 


the  so-called  "  tabetic  foot "  and  "  tabetic  hand."     (See  Figs.  52,  53,  and  54.) 
The  shafts  of  the  bone  may  atrophy  and  spontaneous  fractures  occur.     The 

primary  change  is  probably  always  an  hypertrophy, 
which  is  followed  by  a  pronounced  atro])hy.  When 
the  jaw  is  attacked  the  wasting  of  the  alveolar  ])ro- 
cesses  results  in  the  dropping  out  of  the  teeth,  which, 
though  entirely  sound,  may  be  shed  one  by  (tnc  (»r 
tumble  out  en  masse. 

Perforatinc/  ulcer  may  attack  the  hands  or  probably 
even  the  internal  organs,  but  especially  affects  the  vicin- 
ity of  the  metatar.so-phalangeal  articulations  of  the  feet. 
The  first  symptom  usually  is  a  severe  pain.  This  pro- 
dromic  pain  may,  however,  be  entirely  wanting.  A 
small  hemorrhagic  or  ecchymotic  ^p(>t  now  a|)pears 
under  the  epidermis:  in  the  course  oi'  a  H  \v  hours 
the  skin  detaches  itself,  or  more  fre(iu('nfl\-  becomes 
excessively  thickened  into  a  large,  dry,  corn-like  ma.'^s ; 
a  small  slough  soon  separates,  leaving  the  ulceration 
round,  with  sharp,  acute  edges,  piercing  usually  t(t  the 
dcejHT  tissues  and  in  many  cases  reaching  the  articu- 
\round  the  ulcci'ation  there  is  apt  to  be  serous  infiltration 
and  swellin<r.  The  i)erforatin<;  ulcer  mav  be  recovenMl  from  cither  without 
loss  of  bone  or  with  the  throwing  otf  of  small  necrosed  Hakes,  but  in  most 
<'a.ses  the  bone  becomes  seriously  diseased  and  a  sinus  forms.  In  this  condition 
the  lesion  appears  as  a  small  Mperlui'c  jendiiii:'  l)y  a  mmitow  ^illns  to  diseased 
h()U(\  and  surrounded  l)y  thickened,  sMperini))o-e<|  hiyers  of  c|)i(l<'rmis.  Th(; 
.surface  of  the  spot  is  usually  cold   :im<1   amcsthetie,  the  (  li:ir,nlei'isti(!  ieatnro 


Tabetic  Hand  (after  Ball). 

lation  or  the  bone. 


784  ORGANIC  DISEASES    OF    THE  SPINAL    CORD, 

of  the  ulcer  being  its  insensibility  to  irritants  and  its  freedom  from  pain 
during  rest.  The  attack  may  end  in  death  from  erysipelatous  inflammations 
of  the  foot  and  leg,  or  in  recovery  with  ankylosis  and  various  deformities. 

In  1879,  Vnlpian  called  attention  to  the  frequency  of  valvular  disease  of 
the  heart  in  locomotor  ataxia,  and  his  observations  have  since  been  confirmed 
by  both  German  and  French  writers.  Insufficiency  of  the  aortic  valve  appears 
to  be  the  most  frequent  lesion,  but  any  valve,  and  (fven  the  heart-muscle,  may  be 
involved.  How  far  these  lesions  ought  to  be  considered  as  strictly  trophic  and 
due  directly  to  centric  nervous  disease  is  at  present  uncertain.  Nevertheless, 
when,  as  in  some  cases,  a  sharply-defined  perforating  ulcer  forms  upon  a  valve, 
the  existence  of  a  trophic  influence  can  scarcely  be  denied,  whilst  the  fact  that 
cardiac  lesions  habitually  occur  when  the  cardiac  crises  indicate  diseases  of 
corresponding  centres  is  certainly  noteworthy. 

Termination. — Very  few  of  the  symptoms  of  locomotor  ataxia  in  any  way 
compromise  life,  so  that  even  when  almost  the  whole  length  of  the  spinal  cord 
is  affected  the  patient  may  live  on,  without  control  of  his  voluntary  muscles, 
for  a  quarter  of  a  century.  In  women  tabes  does  not  prevent  successful  preg- 
nancy;  per  contra,  whilst  pregnancy  may  for  the  time  being  hold  in  abeyance 
the  symptoms,  it  has  no  permanent  effect  upon  the  disease.  Usually  in  tabes 
life  is  sooner  or  later  cut  short  by  some  intercurrent  disease ;  especially  are 
the  kidneys  liable  to  become  diseased.  Again,  not  rarely  the  tendency  of  the 
lesions  to  pass  to  other  portions  of  the  nervous  system  leads  to  the  fatal  result. 
Of  all  portions  of  the  nervous  system,  one  of  the  most  prone  to  be  secondarily 
affected  is  the  gray  matter  of  the  cerebrum,  with  result  of  mental  disturbance. 
Under  these  circumstances  violent  insanity,  amounting  even  to  an  acute, 
rapidly-fatal  mania,  may  develop,  but  more  commonly  the  cerebral  symptoms 
are  less  severe,  taking  the  form  it  may  be  of  a  melancholia  or  slowly  develop- 
ing into  a  peculiar  garrulous  imbecility.  Progressive  paralysis  of  the  insane 
and  locomotor  ataxia  not  rarely  coexist,  offering  a  clinical  picture  of  two  inter- 
mingled diseases.  Sometimes  the  one,  sometimes  the  other  affection  a})pears 
to  be  the  first  in  development.  Subacute  myelitis  is  said  sometimes  to  occur 
as  a  complication,  and  the  lateral  columns,  or  even  the  gray  matter,  may  l)e 
involved. 

Diagnosis. — The  diagnosis  of  fully-developed  locomotor  ataxia  is  usually 
so  easy  as  to  require  no  discussion.  The  only  affection  which  resembles  it  is 
the  hysterical  disorder  known  as  astasia  and  abasia  (Jtysterical  ataxia,  auto- 
matic ataxia).  In  this  disorder,  however,  there  is  no  lack  of  co-ordination 
in  the  movements  of  the  limbs  when  the  patient  is  upon  the  back,  even  though 
walking  is  impossible.  The  knee-jerk  is  rarely,  if  ever  lost;  the  pains,  if 
present,  are  cephalalgic  or  rhachialgic,  and  are  very  rarely  if  ever  closely  com- 
parable with  those  of  true  ataxia ;  whilst  the  true  nature  of  the  hysterical 
disorder  is  unmistakably  shown  by  its  suddenness  of  onset,  by  its  irregularity 
of  course,  and  by  the  presence  of  choreic  movements,  convulsions,  globus  hys- 
tericus, or  other  distinctly  hysterical  symptoms. 

The  recognition  of  locomotor  ataxia  in  its  early  stages  is  more  difficult.    The 


LOCOMOTOR    ATAXIA.  785 

most  characteristic  symptoms  are  the  pains,  loss  of  knee-jerk,  loss  of  co-ordi- 
nation, and  the  trophic  and  visnal  phenomena.  Any  of  these  may  precede  the 
others  in  order  of  development,  and  may  continue  for  years  without  other  symp- 
toms :  the  co-existence  of  any  two  of  these  symptoms  renders  the  diagnosis 
almost  certain. 

The  pains  of  locomotor  ataxia  are  usually  to  be  distinguished  from  other 
])ains  by  their  being  bilateral  and  not  associated  with  persistent  tenderness 
either  on  pressure  or  movement.  They  are,  however,  sometimes  so  closely 
simulated  by  fleeting  gouty  pains  that  the  true  nature  of  the  latter  can  only 
be  made  out  by  the  recognition  of  other  symptoms  of  gout. 

The  visual  phenomena  are  most  important,  but  not  absolutely  decisive. 
As  tabes  may  begin  with  a  diploj)ia,  a  strabismus,  or  a  laryngeal  palsy,  any 
such  symptom  occurring  without  obvious  cause  in  a  middle-aged  person,  not 
hvsterical  or  syphilitic,  should  arouse  suspicion. 

When  tabetic  crises  occur  as  a  very  early  symptom,  their  true  nature  may 
be  overlooked :  it  is,  however,  usually  to  be  recognized  by  noting  the  repeti- 
tion of  the  attacks,  the  suddenness  of  their  onset,  the  severity  of  the  pain,  and 
especially  the  rapid  recovery  of  the  functional  activity  of  the  part,  and  the 
absence  of  evidence  of  local  organic  disease  when  the  nerve-storm  is  past. 
Most  of  the  crises  are  dependent  upon  sclerosis  high  up  in  the  spinal  cord  : 
the  lower  extremities  may  be  free  from  disease,  but  failure  in  co-ordination 
in  the  upper  extremities  or  characteristic  ocular  disturbances  may  usually  be 
discovered.  The  cardiac  crisis  is  especially  liable  to  be  mistaken  for  angina 
])ectoris,  but  the  seat  of  the  pain  does  not  actually  corresjK)nd  to  that  of  angina 
])ectoris.  The  focus  is  usually  in  one  or  the  other  axilla,  whilst  the  ])ains  do  not 
radiate  down  the  left  arm,  or,  if  they  do  so,  at  the  same  time  shoot  through  the 
body  itself  and  into  the  right  arm.  The  pains  are  also  more  lancinating  than 
in  angina  pectoris,  and  especially  are  the  individual  paroxysms  more  pro- 
longed. 

Peripheral  neuritis,  when  confined  to  the  lower  limbs,  may  produce  an  ataxia 
with  i)ain  which  has  been  attributed  to  centric  disease.  In  such  a  case,  how- 
ever, there  is  always  tenderness  over  the  nerve-trunks,  whilst  in  locomotor 
ataxia  no  such  tenderness  exists,  except  when  the  centric  disease  is  complicated 
by  neuritis.  Under  the  latter  circumstances  great  care  must  be  exercised  to 
avoid  making  a  mistake.  The  occurrence  of  crises  or  of  visual  symptoms 
would  estal)lisli  the  j)resence  (»f  centric  disease,  l)nt  it  nui.-t  be  remembered 
tliat  gummatous  svjjhiiis  may  sinudtaneously  attack  the  nerves  and  (he  nerve- 
centres,  and  produce  symj)toms  like  those  of  loeoinotor  ataxia,  with  or  without 
neuritis. 

Prognosis. — The  prognosis  of  locomotor  ataxia  is  very  serious,  and  in  the 
fully-formed  disease,  so  far  as  eiiic  is  eoneerned,  I  beli(,'ve  hopeless,  the  few 
reported  cases  of  cure  having,  in  my  opinion,  been  founded  either  in  errt>rs  of 
diatrnosis  or  of  observation  or  in  the  too  carlv  report  of  the  ease.  fiummat<»us 
svphilis  may  give  rise  to  symptoms  very  closely  resend)ling  those  of  hteomotor 
ataxia,  and  be  iclievcd  by  antisyphilitic  treatment.  I  iii|ii(.\  rmciit  ofthe.syni])- 
V.M..  I.— 50 


786  ORGANIC   DISEASES    OF    THE   SPIXAL    CORD. 

toms  under  treatment,  and  indeed  arrest  of  the  disease,  do,  however,  occur  in 
locomotor  ataxia,  especially  in  the  early  stages. 

Treatment. — In  the  management  of  a  case  of  locomotor  ataxia  it  is  of  the 
first  importance  that  all  sources  of  exhaustion  or  of  nervous  depression  be  cut 
off.  Rest,  both  bodily  and  mental,  is  vital.  The  life  of  the  patient  should 
be  permanently  arranged  in  such  a  way  as  to  avoid  all  unnecessary  expenditure 
of  vital  force.  Physical  labor  is  of  course  impossible,  and  mental  work  should 
be  so  reduced  that  it  will  only  be  sufficient  to  divert  the  attention  of  the  patient 
from  himself.  There  can  be  no  doubt  that  the  disease  may  be  sometimes 
arrested,  temporarily  at  least,  by  placing  the  patient  in  bed  for  a  series  of 
weeks,  and  at  the  same  time  using  niassage  to  prevent  the  bad  effects  upon 
the  general  health  which  such  confinement  tends  to  produce.  Even  when  the 
patient  is  going  about  and  in  the  best  condition,  long  walks  should  be  avoided, 
it  being  remembered  that  a  single  hour's  exhaustion  may  overthrow  the  good 
achieved  by  many  Aveeks  of  rest.  The  diet  should  be  nutritious,  but  non- 
stimulating,  and  a  moderate  use  of  wine  is  not  harmful,  although  the  slightest 
excess  of  alcohol  is  certainly  very  deleterious.  Tobacco  must  be  used  only  in 
the  greatest  moderation. 

Sexual  intercourse  should  be  as  far  as  possible  avoided.  It  is  affirmed  by 
good  authority  to  be  especially  harmful  in  those  cases  in  which  there  is  a 
tendency  to  atrophy  of  the  optic  nerve,  with  increasing  impairment  of  vision, 
rapid  blindness  having,  under  these  circumstance,  followed  a  newly-contracted 
marriage.  Whilst  open-air  life  is  useful,  the  most  scrupulous  care  should  be 
exercised  to  avoid  exposure  to  wet  or  cold,  and,  when  it  is  possible  to  the 
patient,  the  winters  should  be  passed  in  a  Avarm,  dry  climate. 

The  effect  of  internal  medication  upon  pure  locomotor  ataxia  is  very  slight. 
Antisyphilitic  treatment  is  of  no  value,  even  though  the  history  of  syphilis  be 
very  clear.  It  is  true  that  medical  literature  abounds  with  reports  of  cases 
which  seem  to  oppose  this  statement,  but  I  have  no  doubt  that  in  such  cases 
the  diagnosis  has  been  incorrect.  Minute  doses  of  mercury — one-fortieth  of  a 
grain  of  corrosive  sublimate — are  believed  by  some  writers  to  be  of  service. 
As  in  these  minute  doses  mercury  has  a  distinct  tonic  influence,  it  is  allowable 
to  employ  it  in  locomotor  ataxia  with  the  hope,  rather  than  the  expectation, 
that  it  may  have  some  influence  upon  the  spinal  lesion.  The  free  use  of  mer- 
cury is  distinctly  contraindicated.  Nitrate  of  silver  Mas  at  one  time  very  com- 
monly employed :  I  have  never  seen  it  achieve  any  good,  but  the  large  his- 
tory of  its  use  justifies  its  employment  by  those  therapeutists  who  have  more 
respect  for  the  statements  of  authorities  than  for  the  results  obtained  under 
their  own  eyes.  Chloride  of  gold  and  chloride  of  barium,  more  recent  rem- 
edies, are  probably  harndess  when  not  given  in  too  large  doses.  If  phosphorus 
have  any  influence  upon  the  spinal  cord,  it  is  that  of  causing  nutritive  excite- 
ment, and  its  administration  would  therefore  ap])ear  to  be  contraindicated  in 
tabes.  Almost  all  of  the  nervine  vegetable  drugs  have  been  given  in  tabes,  but 
there  is  no  reason  for  believing  that  any  of  them  have  a  direct  influence  upon 


LOCOMOTOR    ATAXIA.  787 

the  lesion.  The  active  influence  of  ergot  upon  relaxed  blood-vessels  has  led 
to  its  very  free  use  in  locomotor  ataxia.  There  is,  however,  no  sufficient  reason 
for  believing  that  the  spinal  lesions  are  in  any  degree  due  to  a  preceding  relax- 
ation of  the  blood-vessels.  The  effect  of  ergot  in  producing  tabetic  aifections 
shows  that  the  drug  has  some  influence  u]>on  the  nerve-centres,  and  justifies 
those  who  believe  in  the  doctrine  oi' simi/ia  similibiis  cumnfui'  in  the  me  of  it  in 
small  doses.  I  have  myself  seen  it  used  frequently,  and  have  never  been  able 
to  perceive  the  slightest  good  effects  from  it.  The  favorable  results  which 
have  been  reported  from  it  have  usually  been  in  the  earlier  stages  of  the  dis- 
ease, and  are  alleged  to  have  been  seen  in  the  lessening  of  pain.  These  i)ain- 
symptoms,  however,  vary  so  greatly  and  so  inscrutably  in  the  indivi(hial  case 
that  not  much  importance  seems  to  me  to  attach  to  any  apparent  improvement. 
Certainly  in  locomotor  ataxia  it  is  dangerous  to  give  ergot  in  the  enormous 
doses  which  have  been  employed  by  some  practitioners. 

My  own  belief  is  that  the  employment  of  drugs  should  be  confined  to  the 
administration  of  harmless  remedies,  which  should  give  to  the  patient,  when 
necessary  to  be  given,  the  moral  support  that  comes  to  certain  individuals 
from  the  feeling  that  something  is  being  done;  to  the  giving  of  tonics,  laxatives, 
and  other  mild  remedies  from  time  to  time  as  symptoms  may  call  for  them  ; 
and  to  the  careful  use  of  narcotics  for  the  relief  of  pain.  In  severe  crises 
hypodermic  injections  of  morphine  are  often  necessary,  but  the  practitioner 
must  never  forget  that  the  attempt  to  relieve  the  frequent  attacks  of  sclerotic 
jiain  by  opiates  greatly  endangers  the  formation  of  the  opium  habit.  Anti- 
jn'rin,  antifebrin,  and  phenacetin  certainly  have  a  distinct  controlling  influ- 
ence over  nerve-storms  even  when  due  to  such  deep-seated  cause  as  posterior 
sclerosis.  They  are  much  safer  than  o])ium,  and  I  have  seen  them  relieve  a 
crisis  which  oj)iuin  in  moderate  doses  had  failed  to  control.  It  is  necessary, 
however,  to  carefully  husband  these  remedies,  so  that  their  influence  may  not 
he  worn  out  in  the  course  of  so  long  a  disorder. 

So  far  as  the  disease  itself  is  concerned,  I  do  not  believe  that  any  counter- 
irritation  is  of  avail,  although  some  j)ractitioners  claim  to  have  had  good 
results  from  the  use  of  the  actual  cautery  along  the  sj)ine.  In  the  very  earliest 
stages  of  the  disease  this  may  be  justifiable,  but  certainly  in  the  later  stages 
the  amount  of  relief  does  not  compensate  for  the  suffering  and  distress  involved 
in  the  treatment.  In  cases  of  crises  repeated  mild  counter-irritations,  in  the 
form  of  sinapisms,  over  the  seat  of  the  pain  and  also  over  the  root  of  the  nerve 
supplying  the  affected  part,  are  urgently  called  for  by  moral  reasons.  They 
sometimes  seem  to  bring  relief,  and  may  therefore  always  be  aj^plied,  care 
l)eing  taken  to  see  that  the  application  he  not  sufficiently  severe  to  pi-odiicc 
local  destruction.  Blisters  must  be  employed  undri-  these  circumstances  with 
the  greatest  care,  as  there  is  danger  of  the  local  inflaminalion  becoming  uncon- 
trollal)le.  This  is  especially  true  when  antesthetic  portions  of  the  skin  are 
involved.  Any  bh'sters  or  soi'cs  upon  the  feet  should  always  receive  the  most 
careful  attention,  it  being  affirmed  by  cojupeteut  authorities  that  a  perforating 
ulcer  has  followc<l  so  small  an  oj)cration  as  th<'  cutting  of  a  corn.      In  a  crisis 


788  ORGANIC  DISEASES    OF    THE   SPINAL    CORD. 

the  application  of  moist  heat  in  the  form  of  the  warm  bath  and  hot  fomenta- 
tion is  often  more  successful  than  the  counter-irritant. 

It  is  verv  common  for  cases  of  locomotor  ataxia  to  go  to  certain  springs  for 
treatment,  notably  in  Europe  to  Aix-la-Chapelle  and  in  this  country  to  the 
Arkansas  Hot  Springs.  I  do  not  myself  believe  that  there  is  any  virtue  what- 
ever in  the  water,  at  least  of  our  Arkansas  springs.  Most  cases  of  true  loco- 
motor ataxia  are  not  distinctly  and  permanently  benefited,  and  whatever  good 
is  achieved  is  the  result  of  the  stimulating  effect  of  travel  and  new  scenes,  to 
the  freedom  from  care,  rest,  and  to  the  hydrotherapeutic  measures  employed. 
Very  manv  of  the  practitioners  at  these  hot  springs  ase  mercury  in  enormous 
amounts,  and  old  cases  of  syphilis,  which  perha|7S  have  been  mistaken  for 
sclerotic  disease,  are  often  benefited,  but  the  cases  of  true  sclerosis  are  not 
rarely  greviously  injured.  I  do  not  think  that  these  waters  act  any  differently 
from  waters  that  have  been  heated  artificially,  and  the  home  use  of  the  warm 
bath  or  the  warm  pack  is  often  of  service  in  tabes  by  quieting  the  patient, 
reducing  the  amount  of  pain,  and  aiding  rest  and  massage  in  bringing  about 
relief  One,  two,  or  even  three  warm  baths  or  packs  may  be  employed  daily 
according  to  the  strength  of  the  patient.  The  temperature  of  the  water  should 
not  be  over  100°  F. 

In  all  cases  it  is  essential  that  the  bladder  be  thoroughly  emptied  at  regular 
intervals.  Even  in  the  earlier  stages  micturition  may  be  so  imperfect  that 
there  is  a  residuary  urine,  w^hich  undergoes  fermentation  and  sets  up  a  cystitis, 
that,  although  slight,  may  yet  be  sufficient  to  gradually  involve  the  ureters 
and  the  mucous  membranes  of  the  pelves  of  the  kidneys,  and  finally  the  kid- 
neys themselves.  In  this  is  pro1)ably  found  the  cause  of  frequent  death  from 
kidney  disease  in  locomotor  ataxia.  No  hesitation  should  be  felt,  in  any  case, 
in  using  the  soft  catheter,  and  when  the  urine  is  ammoniacal  the  bladder 
should  be  washed  out  thoroughly  every  other  day  with  a  dilute  solution  of 
some  antiseptic. 

Very  much  has  been  claimed  by  certain  writers  for  the  use  of  electricity 
in  locomotor  ataxia,  but  I  have  myself  never  seen  it  do  the  slightest  good. 
It  has  been  the  habit  of  certain  electro-therapeutists  to  apply  the  galvanic 
current  to  the  spinal  column.  Some  authorities  recommend  that  the  current 
should  be  passed  upward,  some  that  it  should  be  passed  downward,  the  posi- 
tive or  negative  pole,  as  the  case  may  be,  being  placed  at  the  nape  of  the  neck, 
its  antagonist  at  the  end  of  the  spine.  I  do  not  myself  believe  that  under 
these  circumstances  any  portion  of  the  electrical  current  passes  through  the 
thick  bony  enveloj^e  and  reaches  the  spinal  cord.  Every  physiologist  knows 
that  the  slightest  electrical  stimulation  of  the  cord  will  produce  muscular  con- 
traction, but  no  current  that  can  be  used  for  remedial  purposes,  applied  in 
the  manner  just  spoken  of,  ever  provokes  any  evidences  of  spinal  functional 
activity.  For  similar  reasons  I  do  not  believe  it  possible  to  galvanize  the 
cervical  symj)athetic  ganglia,  as  has  been  recommended  by  various  writers,  in 
the  treatment  of  this  and  other  nervous  diseases ;  moreover,  there  is  no  suffi- 
cient clinical  or  scientific  reason  for  believing  that  galvanization  of  these  gan- 


LOCOMOTOR    ATAXIA.  789 

glia,  if  possible,  would  do  any  good.     The  local  use  of  the  wire  brush  witii 


a  current  of  moderate  strength  is   said   to  be  sometimes  useful  in   relievi 


» 


ng 
the  excessive   numbness  of  locomotor  ataxia. 

Two  surgical  procedures  have  been  proposed  for  the  cure  of  tabes,  and  have 
received  sufficient  laudation  to  require  notice  here.  The  first  of  these,  as  pro- 
posed by  Langenbach,  consists  of  the  stretching  of  the  sciatic  or  of  such  other 
nerves  as  take  their  origin  in  the  affected  region.  This  procedure  is  so  devoid 
of  known  scientific  basis  that  I  have  myself  never  felt  justified  in  using  it ;  and, 
although  a  few  cases  of  remarkable  results  have  been  reported,  the  almost  uni- 
versal consensus  of  medical  opinion  is  that  nerve-stret<'hing  in  tabes  is  not 
justifiable.  The  operation  has  itself  caused  death,  and  has  been  followed  by 
inflammation  of  the  spinal  cord. 

In  1883,  Motschoutkowski  published  a  paper  in  the  WraUch  proposing 
the  use  of  suspension  by  the  neck  for  the  cure  of  tabes,  and  giving  account  of 
several  cases  in  which  the  symptoms  of  ataxia  had  been  in  this  way  very 
much  relieved.  Motschoutkowski  believed  that  there  is  an  absolute  stretching 
of  the  vertebral  interspaces  and  a  direct  influence  upon  the  cord,  but  in  the 
present  state  of  our  })hysiological  knowledge  the  use  of  suspension  in  tabes  must 
rest  absolutely  on  empirical  basis,  no  probable  theory  being  at  hand  to  account 
for  the  value  of  the  method,  if  indeed  it  have  value.  The  subject  did  not 
attract  wide  attention  until  its  exploitation  by  Charcot,  whose  reports  were 
most  favorable,  it  being  claimed  that  out  of  50  consecutive  cases  in  his  clinic 
treated  by  suspension,  38  were  undoubtedly  ameliorated.  Thorough  trials  have 
now  been  made  with  suspension  in  every  portion  of  the  civilized  globe,  and 
certainly  the  published  results  do  not  coincide  with  the  enthusiastic  Parisian 
reports.  Thus,  of  75  English  cases  which  I  have  collected  from  various 
papers,  not  one  is  recorded  as  having  received  any  distinct  benefit.  The  Ger- 
man reports  are  scarcely  more  favorable.  In  none  of  the  114  cases  reported  by 
Hirt  was  there  any  very  distinct  result.  In  Professor  ISIcndel's  clinic,  out  of 
61  cases  only  5  distinctly  improved.  On  the  other  hand,  6  cases  of  death 
from  suspension  have  been  reported,  the  death  sometimes  taking  place  during 
the  suspension,  and  sometimes  occurring  within  tiic  t\venty-fi)ur  hours  after- 
ward. Charcot  teaches  that  oedema,  obesity,  phthisis,  valvular  or  other  cardiac 
lesions,  emphysema,  and  marked  atheroma  of  the  arteries  are  contraindica- 
tions to  the  use  of  suspension ;  and  certainly  when  either  of  these  exists  the 
practitioner  is  not  justified  at  all  in  experimenting  with  the  method.  Mot- 
schoutkowski ))ractised  suspension  ten  minutes  three  or  fi)ur  times  a  week  ; 
others  have  used  it  every  few  hours.  It  is  probably  best  to  give  it  once  a  day, 
fW)m  five  to  fifteen  minutes.  Tiu!  best  form  of  apparatus  is  probably  that 
which  is  known  in  America  as  the  Weir  Mitchell.  Space;  is  wanting  for  its 
description.  The  practitioner  should  always  see  that  the  jjatient  is  suspended 
from  a  spring  balance,  so  that  an  absolute  knowledge  of  the  anidiiiit  (.f  force 
used  can  be  obtained. 


790  ORGANIC  DISEASES   OF   THE  SPINAL    CORD. 

Antero-lateral  Sclerosis. 

Definition. — A  disease  due'  to  sclerosis  of  the  antero-lateral  columns  of 
the  spinal  cord,  characterized  by  stiffness  of  the  affected  parts,  marked  mus- 
cular contractions  with  partial  loss  of  power,  exaggerated  reflexes,  without 
pronounced  disturbance  of  sensation  and  without  trophic  changes. 

Synonyms. — Spastic  paraplegia  ;  Spastic  spinal  paralysis. 

Etiology. — Antero-lateral  sclerosis  has  relations  with  syphilis  similar  to 
those  of  locomotor  ataxia;  seems  also  to  be  produced  by  various  poisons, 
notably  lead ;  has  been  believed  by  some  authorities  to  be  the  result  of  sexual 
excesses,  and  appears  not  rarely  to  be  the  outcome  of  excessive  exposure  with 
overwork — in  a  word,  our  present  knowledge  indicates  that  the  causes  which 
produce  in  one  case  posterior  sclerosis,  in  another  case  bring  on  antero-lateral 
sclerosis,  but  give  us  no  clue  for  deciding  why  in  one  case  one  region,  in  another 
case  another  region,  of  the  cord  is  attacked. 

Pathology. — In  spastic  spinal  paralysis  the  lesion  commonly  found  is 
sclerosis  of  the  lateral  columns,  especially  affecting  the  so-called  cross  pyra- 
midal tract,  and  containing  the  fibres  passing  between  the  cerebral  ganglia 
and  the  motor  cells  of  the  cord.  The  microscopical  changes  are  similar  to 
those  Avhich  occur  in  sclerosis  of  the  posterior  columns. 

Symptomatology. — Antero-lateral  sclerosis  is  an  essentially  chronic  dis- 
order, which  is  commonly  developed  in  middle  life,  though  occasionally  seen 
at  either  extreme  of  age.  As  the  lower  segments  of  the  cord  are  usually  first 
affected,  the  disease  generally  first  reveals  itself  by  a  loss  of  endurance  during 
walking  and  a  peculiar  stiffness  and  awkwardness  of  gait. 

Even  before  there  is  distinct  loss  of  power  the  patient  will  be  troubled  at 
night,  especially  after  a  hard  day's  march,  with  clonic  or  tonic  spasms,  which 
cause  the  legs  to  stiffen  suddenly  or  to  be  jerked  about.  A  little  later  the  stiff- 
ness and  loss  of  power  combine  to  produce  a  very  characteristic  gait.  The 
contractures  of  the  various  muscles  prevent  the  bending  of  the  joints  of  the 
knee  and  hip,  whilst  the  great  power  of  the  muscles  of  the  calf  tends  to  draw 
the  heel  up  and  to  thrust  the  toe  downward.  Consequently,  the  foot  can  be 
lifted  from  the  ground,  sufficiently  to  make  a  step,  only  by  raising  and  rotating 
the  pelvis,  so  that  the  body  is  inclined  toward  the  leg  upon  M^hich  the  patient 
rests  during  the  step,  whilst  the  moving  foot  is  slowly  thrust  forward.  The 
toes  appear  to  stick  to  the  ground,  and  are  only  with  the  greatest  difficulty 
sufficiently  raised  to  be  pushed  forward.  The  steps  are  of  necessity  very  short, 
it  may  only  be  three  or  four  inches.  As  the  leg  is  put  forward,  not  rarely 
violent  trembling's  affect  it,  and  in  some  cases  these  movements  are  so  rhyth- 
mical  as  to  throw  the  heels  of  the  patient  up  and  down  in  regular  vibrations. 
As  the  disease  progresses  the  contractures  of  the  muscles  of  the  calf  become 
so  great  that  the  heels  are  j^ormanently  drawn  from  the  ground  and  the  patient 
rests  upon  the  toes.  Under  these  circumstances  the  trunk  is  of  necessity  thrown 
forward,  and  is  preserved  from  fiilling  only  by  means  of  crutches  or  canes  held 
well  in  advance  of  the  body.     A  little  later  than  this  all  power  of  locomotion 


ANTERO-LATERAL    SCLEROSIS.  791 

is  lost,  and  not  rarely  tho  patient  is  confined  to  bed,  or,  if  he  attempt  to  sit, 
nmst  be  propped  up  in  a  chair  with  his  feet  supported  in  front  of  him. 

When  the  power  of  locomotion  is  lost  the  leg  is  usually  flexed  upon  the 
thigh,  the  heel  drawn  up,  and  the  toes  turned  inward,  these  positions  being 
due  to  the  superior  power  of  the  jiosterior  muscles  of  the  thigh  and  leg  and 
of  the  abductor  muscles  as  compared  with  their  antagonists.  In  some  cases 
the  patient  lies  with  the  legs  stiffly  extended,  very  rigid,  the  feet  inverted  and 
often  crossed. 

Tonic  spasm  is  especially  characteristic  of  spastic  paraplegia,  but  very  early 
in  a  case  clonic  spasm  may  occur,  and  even  that  form  of  violent  clonic  spasm 
may  be  present  in  wliich  the  legs  are  vibrated  rapidly  to  and  fro,  and  to  wiiich 
the  very  inappropriate  and  incorrect  name  of  spinal  epilepsy  has  been  given 
by  Brown-Sequard.  This  clonic  spasm  is  especially  apt  to  hai>pen  during  the 
night,  and  is  usually  painless,  but  is  sometimes  accompanied  with  cramp-like 
sensations. 

The  functions  of  the  sexual  organs,  the  bladder,  and  the  rectum  are  usually 
not  implicated  until  very  late  in  the  disorder.  Sensory  symptoms  are  com- 
monly not  present,  or  at  most  are  confined  to  slight  dull  pains  or  a  feeling  of 
weariness  or  slight  numbness  or  paraesthesi a.  When  rheumatoid  pains  with 
distinct  disorder  of  sensibility  occur,  the  probabilities  arc  that  a  neuritis  has 
been  set  up  or  that  the  disease  has  extended  to  other  portions  of  the  sjiinal 
cord. 

There  is  no  wasting  of  the  muscles  and  no  trophic  changes  in  the  joints  or 
other  part.  For  reasons  which  at  present  are  not  very  apparent  tiie  lesion  has 
little  tendency  to  spread  throughout  the  nervous  system,  as  it  does  in  locomotor 
ataxia,  and  hence  ocular  and  laryngeal  implications  are  rare,  as  is  also  mental 
confusion  or  insanity,  although  lateral  sclerosis  and  general  jiaralysis  may 
coexist. 

Very  early  in  the  disorder  the  reflexes,  both  superficial  and  deep,  will  be 
found  involved,  and  their  increase  soon  becomes  excessive.  The  slightest  tap 
upon  the  patellar  tendon  produces  a  quick  and  violent  response,  and  it  is  usually 
possible  to  produce  not  only  an  ankle-,  but  also  a  knee-clonus;  but  in  advanced 
stages  of  the  disease  the  rigidity  of  the  muscles  may  be  so  great  as  to  in  a 
measure  mask  the  condition  of  the  reflexes,  the  muscles  being  already  in  such 
violent  spasm  that  no  open  effect  follows  further  irritation.  In  raic  instMuccs 
the  excitement  of  the  reflexes  dominates  the  condition  of  the  nniscles,  which 
may  be  partially  relaxed  and  quiet  when  the  patient  is  in  bed,  but  are  instantly 
thrown  into  violent  contraction  by  tiie  touch  of  the  floor  during  M(tem])ts  to 
walk. 

The  course  of  spjistic  paraj)l('gia  is  usually  chronic,  the  discasi;  generally 
continuinor  for  manv  vcars  and  having  little  direct  tendcncv  to  shorten  life. 
Chronic  kidney  disease  is  nnich  less  frequent  than  in  locomotor  ataxia,  because 
the  l)ladder  is  so  seldom  iiii|»lica)e(l. 

Diagnosis. — Althoiigli  the  recognilioii  of  the  nature  of  a  case  of  lateral 
sclerosis  is  usually  easy,  sometimes  it  is  almost  imjjossible.     'I'lie  diagnosis  of 


792  ORGANIC  DISEASES    OF    THE  SPINAL    CORD. 

lateral  sclerosi.-?  rests  upon  the  slowness  of  the  development  of  a  gradual  loss 
of  power,  which  is  accompanied  by  muscular  contraction  and  heightened  re- 
flexes, and  so  situated  as  to  be  evidently  of  spinal  origin,  combined  with 
the  absence  of  girdle  sensation,  of  pain,  and  of  disturbance  of  sensation,  of 
paralysis  of  bladder  or  rectum,  of  trophic  changes,  and  of  disorder  of  co- 
ordination. 

The  diseases  which  produce  groups  of  symptoms  more  or  less  closely  simu- 
lating lateral  sclerosis  are  spinal  meningitis,  chronic  cerebral  disease  with  sec- 
ondary degeneration,  and  hysteria. 

Spinal  meningitis  is  accompanied  by  excessive  pain,  and  any  attempt  at  the 
extension  of  the  affected  limbs  produces  suffering  which  is  so  much  greater 
than  that  produced  by  similar  procedures  in  lateral  sclerosis  that  the  diagnosis 
should  always  readily  be  made  out. 

Cerebral  or  secondary  contractures,  especially  as  seen  in  the  disease  known 
as  spastic  paralysis  of  childhood,  are  probably  always  due  to  degeneration  of 
the  antero-lateral  motor  tra(;t  of  the  brain  and  spinal  cord,  produced  by  a 
chronic  inflammation  having  its  origin  in  the  seat  of  the  original  cerebral 
lesion.  The  lesions  in  lateral  sclerosis  and  in  descending  degeneration  follow- 
ing brain  disease  are  so  similar  tliat  of  necessity  the  cerebral  contractures  must 
simulate  those  caused  by  antero-lateral  sclerosis;  but  the  distribution  of  the 
spastic  paralysis  differs  in  the  two  affections.  Cerebral  lesions  are  usually  uni- 
lateral, spinal  lesions  usually  bilateral.  Except,  therefore,  in  rare  cases,  con- 
tractures due  to  secondary  degeneration  are  readily  distinguished  from  those  of 
the  primary  spinal  disease  by  their  being  one-sided.  It  is  true  that  in  spinal 
scilerosis  one  side  of  the  cord  may  be,  at  least  in  the  early  stages,  more  affected 
than  the  other,  and  that  under  these  circumstances  the  symptoms  are  more  pro- 
nounced upon  one  side  than  the  other ;  nevertheless  the  opposite  side  does  offer 
some  manifestation  of  disease.  In  the  diagnosis  between  secondary  and  pri- 
inar}-  contractures  the  history  of  the  case  also  plays  an  important  part.  Spinal 
spastic  paralysis  always  develops  slowly  and  insidiously ;  secondary  contractures 
almost  always  have  followed  an  acute  attack  with  cerebral  symptoms  or  are 
accompanied  by  symptoms  plainly  of  cerebral  origin.  When  spastic  paralysis 
dates  back  to  birth,  unless  due  to  hereditary  syphilis,  it  is  probably  always  of 
cerebral  orio;in. 

The  greatest  difficulties  of  diagnosis  are  in  the  separation  between  hyster- 
ical and  spinal  contractures;  indeed,  it  would  appear  that  organic  contractures 
may  supervene  upon  the  hysterical  variety.  Charcot  reports  the  case  of  a 
woman  in  whom  contractures  of  all  four  extremities  developed  suddenly  and 
continued  for  ten  years,  with  but  few  temporary  remissions.  After  the  last 
seizure  the  contra(^tures  remained  initil  death,  and  at  the  autopsy  symmetrical 
sclerosis  of  the  lateral  columns  was  found  to  extend  almost  the  entire  length 
of  the  cord.  In  one  of  my  own  cases  contractures  which  had  apparently  been 
originally  hysterical  did  not  relax  during  antethesia,  and  Avere  accompanied 
with  much  atrophy  of  the  aff('(;tcd  muscle.  In  accordance  with  the  rule  laid 
down  by  Charcot,  that  whenever  marked  atrophy  of  the  muscles  and  persistence 


ATAXIC   PARAPLEGIA.  793 

of  the  eontrachires  during  amrsthesia  are  present  or</anic  degeneration  of  tlie 
spinal  cord  lias  probably  set  in,  the  diagnosis  in  my  case  was  lateral  sclerosis 
following  an  originally  hysterical  contracture. 

In  opposition  to  this  view  Dr.  Gowers  asserts  :  "  Nothing  resembling  it 
(spastic  paraplegia)  ever  occurs  in  hysterical  paraplegia.  Hysterical  contrac- 
ture is  fixed,  and  does  not  vary  with  posture,  as  does  the  'clasp-knife  rigidity  ' 
of  spastic  paraplegia.  When  the  spasm  is  trifling  or  absent,  as  in  slight  and 
early  cases,  the  diagnostic  difficulty  is  much  greater,  and  is  increased  by  the 
fact  that  slight  excess  of  myotatic  irritability  occurs  in  some  cases  of  so-called 
hysterical  paralysis.  This,  however,  scarcely  ever  reaches  the  degree  necessary 
to  give  rise  to  a  true  foot-clonus  or  a  rectus-clonns.  There  may  be  a  spurious 
foot-clonus,  or  a  true  clonus  may  be  obtainable  if  there  be  hysterical  contract- 
ure, but  apart  from  such  contracture  a  true  foot-clonus  or  a  rectus-clonns  de- 
serves the  greatest  weight  as  all  but  conclusive  evidence  of  organic  disease." 
These  statements  are,  however,  contradicted  by  my  own  clinical  experience.  T 
have  seen  a  most  severe  clonus  in  hysterical  paraplegia  in  which  the  symptoms 
Mere  persistent  for  many  months  without  relief,  and  in  which  the  case  was 
repeatedly  shown  at  a  public  clinic,  both  by  Professor  C.  K.  Mills  and  myself, 
as  one  of  sclerosis,  but  in  which  recovery  occurred  in  the  course  of  a  week 
durins:  the  administration  of  subnitrate  of  bismuth,  I  am  therefore  convinced 
that  a  positive  diagnosis  between  spastic  paraplegia  and  hysterical  paraplegia  is 
not  always  possible  without  a  history  of  the  patient. 

ITsuallv,  however,  the  hvsterical  disorder  can  be  distinguished  bv  the  sud- 
denness  of  its  development,  by  the  history  of  hysterical  attacks  in  the  past, 
bv  the  })resence  of  anesthesia  or  other  distinct  hysterical  symptoms,  and  by 
the  sudden  remissions  of  contractures.  I  do  not  believe  that  the  hysterical 
contracture  alwavs  relaxes  during  etherization. 

Prognosis. — What  was  said  about  the  prognosis  of  locomotor  ataxia  (see 
page  785)  applies  to  antero-lateral  sclerosis,  except  that  this  disorder  is  much 
less  ])rone  to  compromise  life. 

Treatment. — The  treatment  of  lateral  sclerosis  is  precisely  that  of  locomo- 
tor ataxia.  It  is  true  that  less  has  been  claimed  for  the  residts  of  mechanical 
treatment,  "  nerve-stretching  and  suspension,"  but  I  see  no  reason  for  believing 
that  these  procedures  have  more  influence  upon  one  spinal  sclerosis  than  upon 
another. 

» 

Ataxic  Paraplegia. 

Definition. — .\  disease  dejiendent  upon  a  cond)ined  sclerosis  of  the  poste- 
rior and  lateral  columns,  and  presenting  during  life  mixed  symptoms  of  loco- 
motor ataxia  and  spastic  paraplegia. 

Etiology. — The  etiology  is  that  of  spinal  sclerosis. 

Pathology. — C'lironic  spinal  lesions  are  apt  to  overflow  ihe  traef  from 
whi<;h  thev  originallv  started  or  consentaneously  to  invade  se\-ei:il  portions 
of  the  cord.  In  this  way  arisf-  atypical  eases,  ollering  during  life  contradic- 
tory symptoms  of  spinal  disease.      Although  the  e(jnd)inations  in  chronic  spinal 


794  ORGANIC  DISEASES    OF    THE  SPINAL    CORD. 

disease  are  in  nature  various,  two  types  may  be  well  clescribed — ataxic  para- 
pleo;ia  and  amyotrophic  lateral  sclerosis. 

Symptomatolog-y. — Ataxic  paraplegia  usually  comes  on  most  insidiously, 
and  commonly  follows,  in  the  general  development  of  its  symptoms,  a  course 
parallel  to  that  of  other  spinal  scleroses  already  described.  According  as  the 
lesion  affects  chiefly  one  column  or  the  other  the  symptoms  of  the  locomotor 
ataxia  predominate,  or  the  lights  and  shadows  of  the  clinical  picture  are  chiefly 
those  of  the  lateral  sclerosis.  Usually,  the  tendency  of  the  reflexes  to  be  lost, 
so  strongly  pronounced  in  locomotor  ataxia,  is  overcome  by  the  irritation  of 
the  lateral  columns,  and  so  there  are  present  together  a  loss  of  power  of 
endurance,  with  loss  of  co-ordination  and  preservation  or  even  excitation  of 
the  reflexes.  The  sensory  symptoms  are  commonly  not  so  severe  as  in  tabes ; 
fulgurant  pains  are  uncommon  ;  the  girdle  sensation  is  not  present  in  a 
majority  of  cases.  Ocular  disturbance  may  or  may  not  exist.  The  gait  is  a 
curious  mixture  of  that  of  spastic  paralysis  with  that  of  posterior  sclerosis. 

Diagnosis. — Probably  of  all  diseases  hereditary  ataxia  gives  symptoms 
most  resembling  ataxic  paraplegia,  but  in  the  latter  affection  a  nystagmus 
does  not  occur  and  the  family  history  is  wanting;  moreover,  the  knee-jerk  is 
verv  rarelv  lost. 

Prognosis  and  Treatment. — The  prognosis  and  treatment  of  this  com- 
bined sclerosis  are  similar  to  those  of  locomotor  ataxia. 

Amyotrophic  Lateral  Sclerosis. 

Definition. — A  disease  due  to  sclerosis  of  the  pyramidal  tracts  and  atrophy 
of  the  motor  cells  of  the  gray  matter  of  the  spinal  cord,  characterized  by 
trophic  degeneration  of  the  affected  muscles,  with  loss  of  power,  muscular 
contractions,  and  exaggerated  reflexes ;  without  pronounced  disturbance  of 
sensation. 

Etiology. — The  causes  of  amyotrophic  lateral  sclerosis  are  very  obscure. 
It  does  not  appear  to  be  as  closely  connected  with  syphilis  as  are  some  other 
forms  of  spinal  sclerosis. 

Pathology. — The  structural  changes  in  the  spinal  cord  are  those  of  lateral 
sclerosis  and  of  poliomyelitis,  the  anterior  or  direct  pyramidal  tract  being 
much  more  apt  to  suffer  than  in  pure  lateral  sclerosis.  Atrophy  of  the  nuclei 
of  the  cranial  nerves  is  extremely  common.  The  relative  extent  of  the  lesion 
in  various  parts  of  the  cord  differs  very  greatly  in  different  cases,  in  some  the 
sclerosis,  in  others  the  cell-atrophy,  predominating.  There  is,  at  present,  no 
sufficient  reason  for  believing  that  either  one  of  these  lesions  is  secondary  to 
the  other,  although  certain  authorities  do  teach  that  the  sclerosis  is  a  secondary 
degeneration. 

Symptomatology. — The  symptoms  of  amyotrophic  lateral  sclerosis  are  a 
combination  of  those  of  poliomyelitis  and  lateral  sclerosis — namely,  wasting 
of  the  muscles  with  loss  of  power  (poliomyelitis),  spastic  contractions,  and 
heightened  reflexes  (lateral  sclerosis).  The  relative  preponderance  of  one  or 
the  other  of  the  two  sets  of  symptoms  varies  indefinitely  in  individual  cases 


1 


FRIEDREICH'S  ATAXIA.  795 

according  as  to  Mhether  one  lesion  or  the  other  predominates.  The  upper 
extremities  are  usually  affected  first,  the  symptoms  of  the  early  stages  being  a 
sense  of  tire,  loss  of  endurance  of  effort,  slow  wasting  of  the  muscles,  and 
perhaps  some  scarcely  perce]>tible  stiffness.  Occasionally  a  tendency  to  a  hem- 
iplegic  arrangement  of  the  symptoms  is  seen,  and  very  commonly  the  trophic 
changes  predominate  in  the  arms,  the  spastic  symptoms  in  the  legs.  The 
cranial  nerves  are  usuallv  affected  verv  earlv,  and  the  svmptoms  mav  closelv 
simulate  those  of  glosso-labial  paralysis.  Inability  to  whistle,  difficulty  of 
speech,  fibrillary  contractions,  loss  of  power  of  retaining  secretions  in  the 
mouth,  and  finally  impairment  of  deglutition,  occur.  Amyotrophic  lateral 
sclerosis  is  much  more  serious,  so  far  as  life  is  concerned,  than  other  forms  of 
sclerosis,  death  frequently  occurring  in  two  to  four  years  from  changes  in  the 
motor  cells  in  the  medulla  involving  the  vital  functions. 

Diag-nosis. — The  recognition  of  the  tr\ie  nature  of  a  typical  case  of  amyo- 
trophic lateral  sclerosis  is  so  easy  as  to  need  no  further  discussion  here.  It 
does,  however,  seem  necessary  to  point  out  that  there  occur  in  nature  all  grades 
of  lesions  between  the  pure  poliomyelitis  and  the  pure  lateral  sclerosis,  and 
that  if  the  motor  cells  degenerate  very  rapidly  the  loss  of  muscle-tone  may  be 
sufficient  to  more  or  less  completely  mask  the  sclerosis  of  the  white  matter. 
Under  these  circumstances  a  slight  stiffness  of  gait  ("  the  frozen  attitude") 
may  alone  reveal  the  true  nature  of  the  case.  In  a  case  of  spastic  bulbar  par- 
alysis the  symptoms  of  bulbar  poliomyelitis  may  be  so  closely  simulated  that 
the  only  evidence  of  the  sclerosis  is  an  increase  of  the  jaw  reflex. 

Prognosis. — The  prognosis  is  very  unfavorable,  the  disease  being  very 
rarely  if  ever  arrested,  and  death  almost  invariably  resulting  in  from  one  to 
five  years. 

Treatment. — The  only  treatment  of  amyotrophic  lateral  sclerosis  which 
seems  to  have  the  least  chance  of  influencing  the  patient  for  good  is  long-con- 
tinued rest  in  bed,  with  massage  and  careful  nursing. 

Friedreich's  Ataxia. 

Definition. — A  disease  which  occurs  in  various  members  of  the  same 
family,  dependent  upon  degeneration  of  the  posterior  and  lateral  columns, 
characterized  by  ataxic  symptoms,  nystagmus,  contractures,  and  widespread 
paresis,  with  subordinate  disorder  of  sensation. 

Syxonyms. — Hereditary  ataxia  ;  Family  ataxia. 

Etiology. — In  the  causation  of  so-called  hereditary  ataxia  direct  inherit- 
ance from  parents  very  rarely  ai)pcars,  but  in  flic  great  niajority  of  cases  the 
ancestors  of  the  affected  j)ersons  have  sufl'cred  from  various  forms  of  nervous 
disease,  so  that  the  family  stock  is  distinctly  neuroi)athic.  The  iiuj)()rtance 
of  this  is  shown  in  the  fact  that  there  an-  on  record  only  live  or  six  isolated 
cases — i.e.  cases  in  which  only  one  member  of  the  family  was  affcdctl.  Among 
the  generallv  recognized  causes  of  the  disonlci-  an'  citlici'  iiitciii|>ci;uicc,  (uber- 
cnlosis,  or  .svphilis  occurring  in  tli<'  parent,  and  consanguineous  marriage.  Of 
these  alleged  causes,  tuberculosis  seems  the   iiuisl    important.      It  is  |)lain  that 


796  ORGANIC  DISEASES    OF    THE  SPINAL    CORD. 

these  various  fausations  have  only  this  in  common — namely,  a  tendency  to 
lessen  in  the  offspring  general  vitality  and  the  power  of  development  of  the 
various  organs  of  the  bodv.  In  not  rare  cases  Friedreich's  ataxia  seems  to 
have  been  precipitated  by  the  occurrence  of  some  acute  disease,  the  symptoms 
having  developed  after  tyT)hoid  fever,  scarlatina,  inflammatory  rheumatism, 
diphtheria,  etc.  in  a  remarkable  number  of  patients. 

Morbid  Anatomy. — The  characteristic  pathological  changes  of  hereditary 
ataxia  consist  of  sclerosis  of  the  pyramidal  tract  and  of  the  posterior  columns. 
In  almost  all  of  the  autopsies  this  sclerosis  has  extended  the  whole  length  of 
the  cord,  and  in  a  majority  of  the  cases  it  has  involved  the  anterior  pyrauiidal 
or  direct  cerebral  tracts.  It  seems,  however,  not  to  have  been  traced  up  into 
the  cerebrum  itself.  In  a  proportion  of  the  cases  a  large  part  of  the  periphery 
of  the  lateral  column,  the  so-called  cerebellar  tract,  has  been  found  sclerosed. 
The  gray  matter  of  the  cord,  especially  the  column  of  Clarke,  is  usually  more 
or  less  degenerated,  and  indeed  not  rarely  the  nerve-fibres  seem  to  be  materially  " 
reduced  in  number  throughout  the  whole  cord. 

We  have  no  knowledge  as  to  which  portion  of  the  nervous  system  is  first 
affet;ted,  but  it  seems  probable  that  no  portion  of  the  sclerosis  can  really  be  con- 
sidered as  secondary  to  other  portions,  the  widespread  changes  being  the  result 
of  a  common  cause.  The  nature  of  these  changes  reuiains  in  doubt,  but  there 
is  reason  for  accepting  as  correct  the  original  thought  of  Kahler  and  Pick,  that 
the  foundation  of  the  affection  is  the  imperfect  development  of  certain  fibres 
of  the  nervous  system.  There  is  appearance  of  truth  in  the  further  general- 
ization of  Pick,  that  this  failure  of  development  is  due  to  early  vascular  de- 
generation, which  naturally  would  especially  and  primarily  affect  the  posterior 
columns  of  the  cord,  because  this  is  the  most  vascular  part  of  the  cord.  It 
must  be  stated,  however,  that  recent  observers'  affirm  that  there  is  no  alteration 
of  the  vessels,  and  that  in  this  fact  the  lesion  absolutely  differs  from  that  of 
true  locomotor  ataxia.  Sclerosis  and  degeneration  of  the  posterior  nerve-roots 
were  noted  in  all  of  the  eight  autopsies  collected  by  Griffith — a  fact  which  seems 
to  negative  the  assertion  of  Dejerine,  that  Friedreich's  disease  separates  itself 
from  true  locomotor  ataxia  in  that  the  root-zones  of  the  cord  are  not  usually 
affected.  Very  few  examinations  of  the  peripheral  nerves  are  on  record,  but 
Auscher  states  that  whilst  these  nerves  have  not  undergone  degeneration,  they 
are  characterized  by  the  presence  of  a  considerable  number  of  filaments  with- 
out myelin — true  embryonal  nerve-tubes.  If  this  be  correct,  it  seems  possible 
that  the  same  condition  may  have  been  originally  present  in  the  spinal  cords 
of  cases  of  Friedreich's  disease,  and  predisposed  their  subjects  to  the  develop- 
ment of  sclerotic  lesions  upon  the  slightest  provocation.  In  this  view  of  the 
pathology  of  the  disease  the  fact  that  in  so  large  a  proportion  of  cases  the 
symptoms  have  followed  some  acute  infectious  disease  is  very  interesting. 
What  is  needed  is  microscopic  examination  of  spinal  cords  taken  from  mem- 
bers of  strongly  affected  families  who  have  not  themselves  manifested  the 
disease. 

'  Compl.  Renduis  Soc.  Biolog.,  1890. 


FRTEDREICH'S   ATAXIA.  797 

Symptomatolog-y. — Friedreicli's  ataxia  almost  invariably  appears  diiriiifij 
childhood.  Out  of  the  143  cases  tabulated  by  Crozer  Griffith,  about  30  jier 
cent,  developed  the  disease  before  the  sixth  year  of  ajjo,  about  60  per  cent, 
before  the  tenth  year,  and  only  3  per  cent,  between  the  twentieth  and  twenty- 
fifth  years. 

Usually  the  attack  comes  on  insidiously,  without  prodromic  s,vm])toms,  but 
eclam})sia,  vomiting;,  vertigo,  curvature  of  the  spine,  flexion  of  the  toes,  palpi- 
tation of  tlie  heart,  choreiform  movements,  and  other  evidences  of  irregular 
nervous  disturbance  have  been  noted.  The  first  characteristic  svmptom  is 
commonly  a  peculiar  awkwardness  of  movement,  which  may  develop  directly 
in  any  portion  of  the  body,  although  in  the  majority  of  cases  it  is  first  ])resent 
in  the  legs.  In  rare  cases  speech  and  the  lower  and  upper  extremities  hav(> 
been  simultaneously  atfected.  A  monoplegic  and  even  a  hemiplegic  form  of 
attack  have  been  recorded. 

In  contrast  with  true  locomotor  ataxia  the  inco-ordination  is  not  always 
increased  by  closure  of  the  eyes.  In  the  fully-formed  case  the  gait  varies  : 
sometimes  it  resembles  that  exactly  of  true  tabes ;  sometimes  the  aberration 
from  the  norm  sliows  itself  only  in  a  strong  tendency  to  the  lateral  projection 
of  the  foot;  sometimes  the  walk  is  rolling  like  that  of  a  drunken  man.  In 
the  upper  extremities  the  loss  of  co-ordination  is  evinced  by  irregular  jerky 
movements  and  the  inability  to  perform  delicate  acts.  Late  in  the  disorder 
inco-ordination  often  becomes  so  extreme  that  in  the  impossibility  of  properly 
ap])Osing  the  fingers  one  to  another  the  action  of  the  hand  resembles  that  of 
the  paw  of  an  animal.  The  peculiar  condition  which  Friedreich  designates 
the  "  ataxia  of  quiet  action,^'  and  which  he  states  to  be  characteristic  of  the 
disease  and  never  present  in  true  locomotor  ataxia,  is  usually  a  rather  late 
symptom,  and  is  shown  in  the  inability  of  the  subject  to  hold  the  arm  still 
in  extension  or  in  other  quiet  though  somewhat  forced  j^ositions.  In  its  most 
advanced  stage  this  ^^ static  ataxia"  even  produces  peculiar  athetoid  symptoms 
in  the  fingers  -when  lying  in  the  lap,  or  a  wavy  or  non-rhythmic  os(;illation  of 
the  arms  and  leg's  wdien  at  rest.  It  is  verv  common  in  the  head,  causing  a 
])eculiar  oscillation  -which  is  sometimes  described  as  tremor  or,  w  luii  the  oscil- 
lations are  excessive,  as  choreiform  movements.  Sometimes  these  oscillations 
occur  only  under  excitement,  and  sinudate  somewhat  an  intention  tremor. 
Spasms  and  cramps  are  rarely  present. 

In  hereditarv  ataxia  the  knee-ierk  is  usually  abolished  early  in  the  history 
of  the  c-ase.  It  is,  however,  not  always  absent,  as  it  has  been  fi)und  normal  in 
a  nund)er  of  re))orted  cases,  and  in  some  cases  which  seem  in  all  other  rcsju'cts 
to  liave  represented  the  disease  it  has  be(>n  exaggerate*  1.  The  most  probal>le 
explanation  of  these  rare  instances  is  that  in  them  the  liunbar  enlargement  of 
the  spinal  eord  has  not  JK-en  involved.  In  some  of  the  cases  in  which  the 
knee-jerk  has  been  found  exaggerated  ankle-elomis  is  asserted  (ct  have  been 
present.  The  cutaneous  reflexes  escajte  in  the  majorily  of  cases,  but  are  oeea- 
sionallv  diniiuished,  mihI  have  been  n(»t<<l  as  increased. 

Incontinence  of  mine  is  a  vtjry  rare  symptom,  and  the  sexual   organs  often 


798  ORGANIC  DISEASES    OF    THE  SPINAL    CORD. 

lung  preserve  their  integrity.  Initial  muscular  weakness  is  spoken  of  as  a 
symptom,  but  probably  in  a  majority  of  cases  is  apparent  rather  than  real ; 
however,  in  the  advanced  disease  true  loss  of  muscular  power  frequently  occurs, 
and  in  a  case  reported  by  Vizioli  it  became  so  widespread  and  complete  that 
the  patient  was  almost  reduced  to  immobility.  Atrophy  of  the  muscles  is  the 
exception  rather  than  the  rule,  and,  although  the  electro-contractility  of  the 
muscles  is  rarely  disturbed,  the  reaction  of  degeneration  has  been  noted.  Mus- 
cular contractions  are  very  frequent  in  the  later  stages  of  the  disease,  and  not 
rarely  give  rise  to  deformities,  such  as  curvature  of  the  spine  (which  has  been 
noted  in  about  one-third  of  the  cases  reported),  talipes  equinus,  and  other  forms 
of  club-foot,  besides  various  distortions  of  the  limbs,  toes,  and  fingers. 

In  a  few  cases  of  Friedreich's  disease  fulgurant  pains  like  those  of  locomotor 
ataxia  have  been  present  as  an  early  symptom,  but  in  the  majority  of  instances 
they  are  absent  through  the  whole  course  of  the  disease,  the  only  disturbance 
of  sensation  consisting  of  aching  pains,  slight  numbness,  and  various  parsesthe- 
sise.  The  numbness,  formication,  and  tingling  are  rarely  severe,  and  the  girdle 
sensation  has  been  noted  only  in  a  small  proportion  of  the  cases.  Disorder  of 
speech  may  be  an  early,  but  is  usually  a  late,  though  an  almost  universal, 
symptom.  It  varies  in  form  and  intensity  :  sometimes  the  subject  speaks  with 
hesitation  and  a  drawl,  sometimes  the  words  are  thrown  out  in  a  jerky,  almost 
stuttering  manner,  whilst  typical  scanning  has  been  reported.  Irregularity  of 
pitch,  indistinctness  of  utterance,  slurring  of  the  syllables,  in  various  cases  have 
indicated  that  the  laryngeal  muscles  are  affected.  With  these  disturbances  of 
speech  other  evidences  of  bulbar  paralysis  are  often  present.  Evident  lack  of 
control  in  the  movements  of  the  tongue  and  lips,  tremors,  choreic  or  oscillating 
movements  of  the  tono-ue,  fibrillarv  contractions  of  all  the  muscles  about  the 
mouth,  loss  of  power  of  holding  the  saliva  in  the  mouth,  with  a  loss  of  tone 
in  the  muscles  of  expression, — any  or  all  of  these  symptoms  may  be  present 
as  the  outcome  of  a  deep-seated  bulbar  involvement. 

Trophic  changes  of  the  joints  and  bones,  such  as  appear  in  true  tabes,  have 
not  as  yet  been  noted  in  the  hereditary  aifection.  On  the  other  hand,  vaso- 
motor disturbances,  as  shown  by  coldness  of  the  extremities,  blueness  or  lividity 
of  the  surface,  and  even  by  oedema,  are  not  very  infrequent. 

The  eye-symptoms  are  peculiar.  Strabismus  witli  diplopia  sometimes 
occurs;  blepharospasm  with  ptosis  has  been  occasionally  noted;  but  the  charao 
teristic  though  usually  late  manifestation  of  the  disease  is  nystagmus.  This 
may  take  the  form  of  what  Friedreich  calls  *'  ataxic  nystagmus  " — namely, 
oscillating  movements  appearing  when  the  eyes  are  turned  upon  some  object 
held  near;  or  that  of  "static  nystagmus '^ — that  is,  movements  when  the  eyes 
are  suj)posed  to  be  at  rest.  The  pupillary  movements  may  be  sluggish,  but 
they  are  always  present,  and  the  Argyll-Robertson  pupil  has  never  been 
noticed.  Atrophy  of  the  optic  nerve  is  rare.  Vision  is  occasionally  impaired, 
but  contraction  of  the  field  has  only  been  observed  a  few  times.  Color  sense 
seems  not  to  have  been  studied.  It  is  not  rare  for  the  intellect  to  be  dulled  in 
cases  of  hereditary  ataxia,  but  distinct  mental  aberration  is  very  uncommon. 


I 


PROGRESSIVE   MUSCULAR    ATROPHY.  799 

and  there  seems  to  be  very  little  tondeney  in  the  disease  to  distinctly  involve 
the  cerebral  hemispheres. 

The  course  of  hereditary  ataxia  is  always  slow,  death  in  almost  all  cases 
having  been  produced  by  some  intercurrent  atiection.  Survival  after  forty 
years  of  illness  has  been  noted. 

Diagnosis. — The  symptoms  of  Friedreich's  disease  are  so  diverse  and  so 
closely  resemble  those  of  other  scleroses  that  in  some  isolated  cases  there  may 
be  a  difficulty  of  recognition.  Usually,  however,  the  occurrence  of  several 
cases  in  one  family,  the  subordination  of  the  sensory  to  the  motor  svmptoms, 
the  static  inco-ordination,  with  the  subsequent  oscillating  or  choreic  move- 
ments, and  the  presence  of  disturbance  of  speech,  with  nystagmus,  make  ihe 
recognition  of  the  nature  of  the  disorder  verv  easv. 

Prog-nosis  and  Treatment. — The  prognosis  in  Friedreich's  disease  is  abso- 
lutely hopeless,  and  no  known  treatment  is  of  anv  avail. 

Progressive  Muscular  Atrophy. 

Definition. — A  disease  due  to  a  slow  degeneration  of  the  tro})hic  or  motor 
cells  of  the  spinal  cord,  clinically  characterized  by  slowly  progressive  atrophy 
of  more  or  less  restricted  groups  of  muscles,  with  proportionate  loss  of  power, 
and  M-ithout  changes  in  the  electrical  reactions  until  very  late  in  the  disorder. 

Synonyms. — AVasting  palsy  ;  Cruveilhier's  palsy. 

Etiology. — Chronic  sj)inal  muscular  atrophy  is  most  frequent  in  nudes 
i)etween  the  ages  of  twenty-five  and  fifty.  Heredity,  and  especially  indirc<-t 
heredity,  seems  to  have  etiological  influence  in  a  minority  of  cases.  Over- 
work, mental  distress,  exposure,  traumatisms,  and  syphilis  are  all  assigned  as 
causes,  but  their  action  is  very  obscure. 

Pathology. — The  anatomical  changes  found  after  death  from  progressive 
nuiscular  atrophy  involve  the  muscles,  the  nerves,  and  the  spinal  cord.  The 
wasted  muscles  are  exceedingly  pale  in  color  and  show  under  the  microscojio 
various  alterations  in  their  fibres.  Four  of  these  changes  seem  to  be  well 
defined :  first,  narrowing  of  the  fibres,  with  slight  changes  in  striaticm  ; 
second,  fatty  degeneration,  in  which  the  transverse  striation  gives  way  to  a 
gramdar  appearance,  the  granules  increasing  in  size  until  at  last  the  sheaths 
are  simply  occupied  by  fat-globules;  third,  "vitreous  degeneration,"  in  which 
the  muscle-sheaths  contain  only  a  clear  material  veiy  faintly  striated  and  cuii- 
taining  fat-globules;  fourth,  an  a])parently  longitudinal  splitting  u|)  cif  the 
fibres,  with  degeneration  of  the  transverse  .striation,  or  in  other  cases  with  the 
:ip])earance  of  the  transverse  striation  much  finer  than  normal,  this  condition 
being  fitllowed  by  the  accumulation  of  latty  globules  and  wasting  of  the  fibre. 
Fn  all  these  cases  the  fibre  is  ultimately  destroyed,  the  sheaths  being  left  empty 
and  shriuiken,  but  clearly  distinguishable  from  the  interstitial  libi-ous  tissue. 

The  ])eriplieral  nei'ves  contain  many  fd)res  undergoing  a  degeneration 
which  ends  in  total  destru('tion  of  the  ih  r\( -lilaiiieiit-,  leaving  onlv  their 
cMij)ty  sheaths.  Tiiis  degeneration  apjx'ars  to  alleet  e.uliot  the  anterior  roots, 
where  it  is  always  exceedingly  pronounced  ;    the  posterior  roots  are  normal. 


800  ORGANIC  DISEASES    OF    THE  SPINAL    CORD. 

The  spinal  cord  usually,  if  not  always,  shows  two  distinct  degenerations. 
In  old  cases  sclerosis  of  both  direct  and  crossed  pyramidal  tracts  is  probably 
always  present.  When  the  amount  is  so  great  as  to  dominate  the  ganglionic 
change  and  to  manifest  itself  during  life  by  symptoms,  the  case  represents 
so-called  amyotrophic  lateral  sclerosis.  In  the  gray  matter  the  ganglionic 
cells  are  always  affected.  The  cells  waste,  losing  their  processes,  becoming 
globular  or  irregular  in  form,  and  afterward  being  reduced  to  little  angular 
masses  which  by  and  by  disapjiear  entirely.  In  the  foci  of  most  advanced 
disease  all  traces  of  the  ganglionic  cells  have  disappeared.  The  nerve-fibrillse, 
which  are  prolongations  of  the  processes,  are  probably  affected  very  early  in 
the  disease :  they  are  found  wasted,  or  more  commonly  do  not  exist  at  all, 
being  replaced  by  the  connective-tissue  elements,  prominent  among  which  are 
small  angular  stellate  cells.  The  larger  vessels  are  often  distended,  the  minute 
vessels  not  much  changed.  The  degeneration  of  the  ganglionic  cells  is  in 
typical  cases  confined  to  the  anterior  cornua,  the  posterior  cornua  remaining 
normal. 

The  onset  of  progressive  muscular  atrophy  is  always  very  slow  and  insid- 
ious. In  most  cases,  before  any  marked  change  can  be  noted  in  the  muscle,  the 
sufferer  perceives  a  loss  of  endurance,  so  that  the  part  tires  easily,  or  there  may 
even  be  absolute  loss  of  power  for  short  exertion.  Careful  examination  will 
now  show,  even  if  there  be  no  sensible  wasting,  that  the  muscle  is  softer  and 
more  flaccid  than  normal.     Sensibility  is  not  impaired. 

A  symptom  which  often  precedes,  although  it  varies  very  greatly  in  amount 
in  various  cases,  any  marked  change  in  the  volume  of  the  muscle  are  fibrillary 
contractions.  In  their  mildest  form  the  fibrillary  contractions  consist  of 
slight,  irregular  twitchings,  occupying  now  this,  now  that  portion  of  the  belly 
of  the  muscle,  and  producing  no  effect  except  a  corresponding  movement  of 
the  skin  over  the  contractions.  In  their  severest  manifestations  the  fibrillary 
contractions  may  amount  to  stormy  peristaltic  movements  hurrying  through 
tiie  muscle  one  after  the  other  in  immediate  repetition.  When  the  fibrillary 
contractions  are  very  severe  the  disease-process,  at  least  in  my  experience,  is 
rapid,  the  wasting  of  the  muscle  notably  increasing  from  day  to  day  under 
observation.  In  the  slowest  forms  of  the  disease,  in  which  many  months  or 
even  years  are  required  for  much  destruction,  the  fibrillary  contractions  are 
usual Iv  sluffirish. 

The  loss  of  power  takes  the  form  of  a  multiple  paralysis ;  that  is,  groups 
of  nmscles  more  or  less  isolated  are  attacked  in  different  ]>arts  of  the  body. 
In  the  majority  of  cases  the  changes  are  somewhat  symmetrical.  Thus,  if  one 
region  of  the  hand  be  attacked,  the  same  region  upon  the  other  hand  will  be 
affected.  This  rule  is  not  invariable,  and  even  when  the  symmetry  is  decided, 
it  may  often  be  noted  that  not  precisely  the  same  muscles  are  affected  upon  the 
opposite  side  of  the  body.  Although  loss  of  endurance,  or  even  partial  par- 
alysis, may  apparently  precede  the  loss  of  muscular  substance,  the  loss  of  power 
is  due  to  the  loss  of  nuiscular  substance,  and  not  the  loss  of  substance  to  the 
loss  of  power ;   or,  perhaps  more  correctly,  it  may  be  considered  that  both 


PROGRESSIVE   MUSCULAR    ATROPHY.  801 

symptoms  have  a  common  basis — i.  e.  when  a  spinal  ganglionic  cell  is  attacked 
the  fibras  of  the  mnscles  individually  supplied  by  it  suffer  simultaneously  in 
their  luitrition  and  in  their  motor  functions.  Usually  the  hands  are  the  first 
portions  of  the  body  to  be  affected,  the  symptoms  frequently  being  much  more 
severe  in  the  right  hand. 

According  to  Eulenberg,  the  interosseous  muscles  are  almost  invariablv  the 
first  to  be  attacked,  whilst  Roberts,  Wachsmuth,  and  Friedreich  state  that  the 
Ijall  of  the  thumb  is  usually  implicated  before  the  interosseous  muscles.  The- 
first  external  interosseous  is  said  to  be  the  fii-st  to  feel  the  influence  of  the  dis- 
ease, whilst  the  opponeus  and  the  adductor  pollicis  are  more  apt  to  suffer  than 
the  extensors,  the  abductors,  and  the  flexors  of  the  thumb.  In  the  few  cases 
in  which  I  have  had  an  opportunity  to  see  the  disease  in  its  earliest  stage  the 
interosseous  muscles  were  the  first  affected.  The  wastins:  of  the  muscles  of 
the  hand  is  usually  readily  perceived  by  the  flattening  of  the  thenar  eminence 
and  by  the  falling  in  of  the  interosseous  spaces.  The  diminished  power  of 
the  interosseous  muscles  can  usually  be  detected  by  noticing  that  when  the 
])atient  attempts  to  abduct  the  index  finger  he  separates  it  with  less  vigor  from 
the  middle  finger  than  normallv.  "When  onlv  (»no  hand  is  attacketl  the  con- 
trast  of  movement  is  often  decided. 

Instead  of  attacking  the  hand,  progressive  muscular  atrophy  may  first  make 
itself  felt  in  other  portions  of  the  body,  and  especially  is  this  true  of  the  del- 
toid muscle  ;  but  it  is  stated  that  the  pectoralis  major,  the  scrratus  magnus,  or 
even  the  lumbar  muscles  may  have  to  bear  the  onset.  The  upper  extremities, 
the  neck,  and  the  trunk  are  certainly  much  more  frequently  affected  than  are 
the  legs ;  nevertheless,  the  latter  do  not  always  escape. 

Owing  to  the  loss  of  power  in  certain  muscles  and  to  the  tendency  to  con- 
tractures in  their  antagonists,  the  sufferers  from  progressive  muscular  atrophy 
are  prone  to  assume  peculiar  positions  or  to  have  extraordinary  deformities. 
In  a  patient  under  my  own  care  the  loss  of  power  in  the  nniscles  of  the  neck 
was  so  great  that  the  head  perpetually  fell  forward,  the  chin  resting  upon  the 
breast.  In  this  case  the  upper  arms  were  much  more  prominently  affected 
than  were  the  forearms,  so  that  whilst  the  man  still  preserved  a  good  grip  the 
arms  were  perfectly  flaccid  and  helpless,  owing  to  the  complete  paralysis  of 
the  deltoid,  biceps,  and  triceps. 

The  most  characteristic  of  the  deformities  is  tliat  which  is  known  as  the 
''clawed  hand"  (main  en  grife,  Khuenhand).  iind  which  is  j)rodiieed  by  the 
l)ermanent  flexion  oi'  the  last  two  plKilau<_res  of  the  fingers,  which  an-  extendcHl 
at  the  metacarpal  joint.  As  was  shown  l»y  Dnehenne,  this  defijrmity  is  the 
result  of  atrf>phy  of  the  internal  and  external  interossecjus  nuisdes  with  the 
preservation  of  power  Ijy  the  extensors  and  flexors  of  the  fingers.  It  nuist  be 
remembered  that  this  deformity  is  really  pathognomonic  of  paralysis  of  the 
interosse<jus  muscles,  and  is  characteristic  of  progressive  muscular  atrophy  only 
for  the  reason  that  loss  of  power  of  the  interosseous  nuis^-le  is  rare  from  oth<'r 
causes.  If,  however,  from  local  disease  of  the  nerves  the  interosseous  rjiusclf^ 
are  paralyzed,  the  clawed  hand  is  developed.  If  only  one  hand  be  clawed,  the 
Vol..  I.— Jl 


802  ORGANIC  DISEASES    OF    THE   SPINAL    CORD. 

suspicion  of  local  disease  should  be  at  once  aroused.  When  the  muscles  about 
the  shoulder-joint  are  paralyzed,  either  by  sharing  in  the  trophic  changes  or  by 
the  loss  of  the  support  of  the  muscles,  the  ligaments  suffer  elongation,  and  the 
joints  become  very  loose,  so  that  a  subluxation  readily  occurs. 

A  very  important  symptom  in  the  diagnosis  of  progressive  muscular  atrophy 
is  the  preservation  of  the  electro-muscular  contractility.  This  at  first  sight 
may  appear  to  be  at  variance  with  the  theory  that  the  lesion  in  the  muscle  is 
the  result  of  destruction  of  the  trophic  cells  in  the  anterior  cornua  of  the  spinal 
cord.  The  explanation  of  the  paradox,  however,  is. simple.  The  destruction 
of  the  ganglionic  cells  progressively  involves  individual  cells  one  after  the 
other,  and,  consequently,  the  trophic  destruction  of  the  muscles  compromises 
individual  bundles  of  fibres  one  after  the  other.  The  muscle,  therefore,  loses 
power,  not  en  masse,  but  fibre  by  fibre,  and  that  portion  of  the  muscle  which 
retains  its  functional  activity  preserves  its  normal  electrical  reactions. 

I  have  never  seen  the  reaction  of  degeneration  demonstrated  in  progressive 
muscular  atrophy,  although  it  is  affirmed  by  Eulenberg  that  in  the  later  period 
of  the  disease  there  may  be  qualitative  alterations  in  the  muscular  reaction — 
i.  e.  an  increased  reaction  under  anodic  closure  and  less  commonly  under  cathodic 
opening.  Eulenberg  states  that  he  has  never  seen  in  progressive  muscular 
atrophy  extreme  degrees  of  qualitative  deviation  from  the  normal  reaction. 
The  so-called  diplegic  contractions  which  Remak  has  affirmed  to  be  of  frequent 
occurrence  in  progressive  muscular  atrophy  are  rarely  to  be  demonstrated. 
The  following  paragraph  from  Eulenberg  explains  the  method  of  developing 
these  contractions  : 

"  Remak  found  that  the  contractions  could  be  produced  in  the  atrophied 
muscles  of  the  arm  when  the  positive  electrode  was  placed  in  an  '  irritable 
zone,'  which  extends  from  the  first  to  the  fifth  cervical  vertebra,  or,  still  better, 
in  the  carotid  fossa  or  the  triangle  between  the  lower  jaw  and  the  external  ear, 
while  the  negative  was  put  below  the  fifth  cervical  vertebra.  The  contractions 
were  always  on  the  side  opposite  to  the  anode,  but  when  the  electrodes  were 
applied  in  the  median  line  they  occurred  on  both  sides.  If  the  current  was 
very  weak  they  were  limited  to  the  muscles  most  severely  affected.  Remak 
regarded  these  as  reflex  contractions  originating  from  the  superior  cervical 
ganglion  of  the  sympathetic,  and  especially  as  the  patient  perceived  a  sensation 
behind  the  ball  of  the  eye  when  the  current  was  closed." 

In  some  cases  of  progressive  muscular  atrophy  the  response  to  the  faradic 
current  appears  more  active  than  normal.  This  may  in  some  instances  be  due 
to  wasting  of  the  muscle,  enabling  the  (airrent  more  rapidly  and  thoroughly 
to  reach  the  portion  of  the  muscle  left ;  but  it  would  seem  that  there  is  somt^- 
times  a  heightened  irritability  of  the  mnsc;ular  fibres  which  have  not  suffered 
degeneration  ;  and  I  have  thought  that  this  was  especially  present  when  the 
fibrillary  (contractions  were  very  severe.  Arain,  in  those  cases  in  which  the 
muscle  as  it  wastes  is  replaced  by  fatty  tissue  the  electro-muscular  contractility 
may  ap])ear  to  be  below  normal  on  account  of  the  resistance  which  the  fatty 
matter  offers  to  the  faradic  current. 


PROGRESSIVE   MUSCULAR    ATROPHY.  803 

The  condition  of  the  reflexes  varies ;  there  is,  of  course,  no  change  in 
unaffected  muscles.  Probably  owing  to  the  sclerotic  changes  which  affect  the 
disease  the  myopathic  irritability  is  very  frequently  increased.  In  advanced 
stages,  however,  it  may  be  diminished  or  even  lost.' 

When  the  lesions  of  progressive  muscular  atrophy  are  situated  high  up  in 
the  spinal  system  the  involvement  of  the  muscles  of  the  head  and  fiice  gives 
origin  to  peculiar  groups  of  symptoms,  one  or  two  of  which  have  been  described 
as  distinct  diseases. 

Ophthalmoplegia  progressiva  of  Von  Graefe  {0.  externa  of  Hutchinson)  may 
be  caused  by  pressure  on  the  nerve-trunks,  but  probably  in  the  majority  of 
eases  is  due  to  the  lesion  of  progressive  muscular  atrophy  attacking  the  nuclei 
of  the  affected  muscles.  In  it  all  the  external  muscles  of  the  two  eyes  are 
more  or  less  completely  paralyzed.  If  the  palsy  be  nearly  complete,  there  is 
marked  drooping  of  the  upper  lid,  with  complete  immobility  of  the  eyeballs, 
giving  rise  to  a  very  peculiar  expression  of  the  face.  Usually  the  internal 
muscles  of  the  eye  are  also  implicated,  but,  according  to  Mr.  Hutchinson,  they 
occasionally  escape. 

Glosso-labial  Paralysis,  first  described  by  Duchcnne  in  1861,  is  a  pro- 
ixressive  muscular  atrophy  in  which  the  degeneration  of  the  motor  nuclei  in 
the  medulla — that  is,  in  the  upper  physiological  segment  of  the  spinal  cord — 
jiroduces  a  progressive  palsy  of  the  tongue,  lips,  palate,  and  throat  muscles. 
The  degeneration  of  the  nuclei  of  the  medulla  may  accompany  that  of  other 
spinal  ganglia  when  the  patient  suffers  from  both  progressive  muscular  atrophy 
and  glosso-labial  paralysis,  or  the  bulbar  nuclei  may  alone  suffer  when  a  pure 
glosso-labial  palsy  results.  The  mode  of  onset  varies:  frequently  the  paresis 
of  the  tongue  is  the  first  to  appear,  but  the  tremulousness  and  loss  of  the  labial 
articulation  may  precede  the  lingual  affection. 

The  course  of  the  disease  is  entirely  parallel  with  that  of  other  forms  of 
progressive  muscular  atrophy.  There  are  the  same  progressive  weakness,  the 
same  slow  wasting,  and  the  same  fibrillary  contractions  in  the  affected  muscles, 
with  persistent  retention  of  electro-contractility,  as  in  other  forms  of  progressive 
atrophv.  The  tongue  is  protruded  more  and  more  slowly  and  imperfectly,  and 
becomes  more  and  more  tremulous.  Owing  to  loss  of  control  over  it  the  i)ro- 
nnnciation  of  the  Ungual  vowels  and  of  the  dental  consonants  is  imperfect. 
The  weakness  of  the  lips  shows  itself  by  failure  in  articulation  of  the  labial 
consonants,  by  tho.  inability  to  whistle,  by  tremulousness,  and,  finally,  by  the 
loss  of  the  power  to  contain  the  saliva  in  the  month,  which  dribbles  constantly. 
As  the  disease  is  almost  always  symmetrical,  the  mouth  is  ii(i(  drawn  to  one 
side,  but  the  wasting  of  the  parts  about  it  may  be  sufficient  to  make  the  orifice 
appear  much  larger  than  normal  and  to  confuse  the  ii;iso-lal)ial  folds.  Son)e- 
times  the  lips  during  laughter  separate  themselves,  l.nl  aiv  iMcai)al)le  of  spon- 
taneously returning  t(t  their  natural    position,  so  that   tlic  patient    is  fi weed  to 

'  It  must  he  r<rri(inl)cre(l  that  the  Beparation  of  amyotrophic  latoral  sclerosis  as  a  distinct 
disease  is  an  artificial  division,  and  that  cases  in  nature  jjradc  np  from  those  witli  least  sclerotic 
changes  to  those  in  whidi  the  sclerotic  chanRcs  are  dominant  over  the  K:"iKli'>"if- 


804  ORGANIC  DISEASES    OF    THE   SPINAL    CORD. 

replace  them  with  his  fingers.  If  the  palate  be  markedly  affected,  the  voice 
becomes  nasal.  Deglutition  may  be  affected  early  or  late  in  the  disorder,  and, 
as  the  loss  of  power  of  swallowing  is  paralytic,  liquids  are  swallowed  with 
much  difficulty  and  are  apt  to  be  returned  through  the  nose.  In  some  in- 
stances the  larynx  is  attacked  and  the  voice  becomes  almost  inaudible,  witfiout, 
however,  being  completely  lost.  In  those  cases  in  which  the  nuclei  of  the 
respiratory  nerves  are  implicated  the  respiratory  muscles  undergo  wasting  and 
the  respiration  becomes  much  affected.  Any  attempt  at  violent  movement, 
or,  later  in  the  disease,  even  ordinary  walking,  may  cause  a  severe  attack 
of  dyspncea.  At  last  these  cyanotic  crises  comes  on  spontaneously  in  furious 
paroxysms,  which  may  occur  either  by  day  or  by  night.  A  peculiar  symptom 
which  especially  characterizes  this  dyspnoea  is  a  sensation  of  excessive  fulness 
of  the  chest,  which  is  probably  produced  by  the  feebleness  of  the  muscles  pre- 
venting them  from  thoroughly  emptying  the  lungs.  In  some  cases  the  nuclei 
of  the  cardiac  nerves  appear  to  be  attacked,  and  cardiac  crises  become  violent 
and  alarming.  These  are  especially  apt  to  be  present  in  those  persons  in 
whom  the  respiration  is  affected,  l)ut  may  occur  without  the  respiratory  mus- 
cles suffering.  The  pulse  in  the  cardiac  crises  is  very  feeble,  irregular,  inter- 
mittent, and  at  last  may  be  imperceptible.  The  face  is  exceedingly  pale  and 
anxious,  and  there  is  habitually  an  intense  terror,  with  a  sense  of  impending 
death.  The  ocular  muscles  may  be  affected  in  glosso-labial  paralysis,  although 
they  usually  escape. 

The  "ophthalmoplegia  externa"  of  Hutchinson  is  in  some  cases  the  expres- 
sion of  a  progressive  muscular  atrophy. 

Diagnosis. — The  slow  progression  of  the  symptoms,  the  occurrence  of 
atrophy  before  paralysis,  the  preservation  of  the  electrical  relations  of  the 
muscles,  the  absence  of  distinct  disturbances  of  sensation  and  of  pronounced 
tenderness,  make  the  recognition  of  progressive  muscular  atrophy  usually 
very  easy.  The  only  disease  with  which  it  can  be  confounded  is  pseudo- 
hypertrophic paralysis.  This  disease,  however,  belongs  to  childhood,  and  is 
usually  attended  with  apparent  increase  in  the  size  of  some  of  the  muscles. 
(For  further  details  see  Pseudo-hy[)ertrophic  Paralysis.) 

Prog-nosis  and  Treatment. — The  prognosis  of  progressive  muscular 
atrophy  is  hopeless.  The  treatment  is  to  be  conducted  upon  general  principles, 
with  especial  avoidance  of  muscular  fatigue.  We  have  no  known  agent  capable 
of  curing  the  degenerative  lesion,  but  possibly  the  conjoint  use  of  rest  and 
massage  may  delay  the  process.  Experience  seems  to  show  that  the  local  treat- 
ment of  the  muscles  by  electricity,  massage,  etc.  is  of  very  little  avail ;  it  may, 
however,  be  essayed,  care  being  taken  not  to  overdo  the  matter. 


DISEASES  OF  THE  NERVES. 

By  WILLIAM  OSLER^ 


NEURITIS. 

Inflammation  of  the  nerve-fibres  may  follow  direct  injury,  disease  of 
neighboring  parts  by  extension  (as  in  suppurative  processes),  exposure  to  cold, 
and  is  frequently  due  to  toxic  agents. 

For  convenience  of  description  localized  and  general  forms  may  be 
recognized. 

Localized  Neuritis. 

Etiology. — (1)  Injury  is  the  most  frequent  cause,  either  direct  laceration 
by  fractures,  gun-shot  and  other  wounds,  or  bruising,  as  in  prolonged  pressure 
upon  a  nerve-trunk.  In  the  subcutaneous  injection  of  ether  an  intense  neur- 
itis may  be  excited  by  puncture  of  a  nerve.  A  rare  cause  is  the  direct  mus- 
cular compression  of  a  nerve  during  sudden,  violent  muscular  exertion.  In 
certain  occupations  pressure  on  the  nerves,  as  upon  the  ulnar  in  glass-workers, 
possibly,  too,  the  constant  straining  of  the  muscles  and  of  the  nerves  in  re- 
peated movements,  as  in  rolling  cigarettes,  may  cause  local  neuritis. 

(2)  Extension  of  inflammation  from  neighboring  parts,  particularly  from 
disease  of  the  bone.  In  otitis  media  the  facial  nerve  may  be  involved,  and 
in  caries  of  the  spine  the  intercostal  nerves.  Syphilitic  disease  is  a  loss  fre- 
quent cause.  Tumors  of  various  sorts,  particularly  cancer,  may  involve  the 
nerve-trunks  and  produce  an  intense  neuritis. 

(3)  Cold.  The  direct  action  of  cold  may  cau.ee  neuritis,  a  common  exam- 
ple of  which  is  in  the  facial  nerve  after  exposure  to  a  draught  of  air,  as 
from  an  open  window  of  a  railway-carriage.  This  is  .sometimes  spoken  of 
as  a  rheumatic  form.  Less  commonly  other  nerves,  such  as  the  sciatic  or 
branches  of  the  brachial  plexus,  are  affected  by  cold. 

(4)  Neuritis  is  not  an  infrequent  accom|>aiiitnent  of  joint-disease,  particu- 
larly periarthritis  of  the  shoulder,  hip,  and   knee. 

And  lastly,  the  various  toxic  agents,  which  will  bi'  considered  under  Midti- 
ple  Neuritis,  though  nioi'c  fi('r|uently  causing  disseminated  lesions,  may  act 
upon  a  single  nerve  or  a  single  ncrvc-i"oot. 

Morbid  Anatomy. — \n  acute  neuritis  tlic  iicrvc-lrunk  is  swollen,  the 
sheath  reddened  and  infiltrated,  and  in  the  nuirc  intense  grades,  du<>  to  exten- 
sion of  inflammation  from  carious  bone,  then  may  be  a  suppurative  perineur- 
itis.    In   the   majority  of  examples  the  connective  tissue  uniting  the  ncrve- 


806  DISEASES    OF    THE   NERVES. 

fibres  is  infiltrated  with  serum  and  leucocytes,  the  nuclei  of  the  sheath  of 
Schwann  are  increased,  and  there  is  marked  fragmentation  of  the  medulla. 
The  axis-cylinders  become  varicose,  and  finally  granular  and  disintegrated. 
In  the  final  stage  the  nerve  is  represented  by  a  very  fatty  connective  tissue. 

Symptoms. — There  is  no  constitutional  disturbance  unless  the  process 
extends  and  involves  many  nerves.  There  is  pain  both  in  the  part  of  the 
nerve-trunk  involved  and  in  the  region  to  which  it  is  distributed.  There  is 
sensitiveness  on  pressure,  and  the  nerve-trunk  may  be  felt  to  be  enlarged.  As 
Weir  Mitchell  states,  the  pain  is  in  all  probability  due  to  the  irritation  of  the 
nervi  nervorum.  In  the  region  of  distribution  there  are  marked  sensory  dis- 
turbances, such  as  numbness,  tingling,  and  often  pain  of  a  shooting  or  a  stab- 
bing character,  which  may  radiate  over  adjacent  nerve-territories.  INIovements 
of  the  muscles  to  which  the  nerve-fibres  are  distributed  may  be  impaired,  and 
occasionally  there  are  tvvitchings  or  spasms.  Trophic  changes  are  sometimes 
seen,  the  temperature  in  the  affected  part  may  be  raised,  the  skin  is  sometimes 
reddened,  local  sweating  may  occur ;  more  serious  changes  are  herpes  zoster 
and  arthritis.  The  duration  of  the  symptoms  is  variable.  A  slight  traumatic 
neuritis  may  pass  away  in  a  week  ;  very  frequently  the  process  becomes  chronic 
and  persists  for  months.  In  the  more  chronic  cases,  such,  for  instance,  as  the 
neuritis  of  the  brachial  plexus  after  dislocation,  the  nerve-cords  are  swollen 
and  painful,  the  pains  persist  for  some  time  in  the  arm  and  hand,  and  the 
muscles  gradually  waste  ;  in  the  more  extreme  cases  the  skin  becomes  red- 
dened and  glossy  and  there  are  trophic  changes  in  the  joints  and  in  the  finger- 
nails. 

Although,  as  a  rule,  the  symptoms  of  a  localized  neuritis  are  confined  to 
the  part  of  a  nerve  affected  and  its  peripheral  distribution,  there  are  instances 
in  which  the  process  ascends  the  nerve,  the  so-called  migrating  neuritis;  thus, 
after  an  injury  to  a  finger  in  which  the  nerves  are  involved,  sensitiveness  and 
swelling  of  one  of  the  nerve-trunks  of  the  arm  may  supervene,  and  the  pro- 
cess may  even  extend  to  the  corresponding  cord  in  the  brachial  plexus.  Gowers 
thinks  that  the  ascending  neuritis  may  even  reach  the  spinal  cord  and  cause 
subacute  or  chronic  myelitis,  and  that  the  so-called  reflex  ])aralysis  in  vis- 
ceral disease  is  perhaps  caused  in  this  way. 

The  electrical  changes  in  localized  neuritis  are  variable,  depending  on  the 
extent  of  the  inflammation.  If  slight,  the  nerve  and  muscle  reactions  may 
be  but  little  disturbed.  In  other  cases  the  reaction  of  degeneration  develops 
rapidly. 

Multiple  Neuritis  (Peripheral  Neuritis  ;  Polyneuritis). 
Etiology. — The  cases  may  be  classified  as  follows:  1,  those  in  which  the 
disease  sets  in  after  exposure  to  cold  or  follows  exertion,  the  so-called  idio- 
pathic form  ;  2,  toxic  form,  by  far  the  most  important  variety,  causing  which 
the  following  poisons  may  be  mentioned  : 

(a)  Diffusible  Stimulants:   alcohol,  carbon    monoxide,  carbon    bisulphide, 
dinitro-benzine  (roburite),  aniline. 


NEURITIS.  807 

(6)  Metallic  Poisons:  lead,  arsenic,  mercury,  and  phosphorus. 

(c)  Animal  Poisons:  diphtheria,  typhus  and  other  fevers,  syphilis,  tubercle, 

malaria,  and  leprosy. 

(d)  Vegetable  Poisons:  ergot,  morphine,  etc. 

(e)  Endof/enous  Poisons:  rheumatism,  gout,  arthritis,  diabetes,  the  puer- 

peral state,  chorea  (James  Ross). 
3,  dyscrasic  form,  in  which  the  neuritis  develops  in  the  cachectic  states,  such 
as  cancer,  anaemia,  and  marasmus  ;  4,  endemic  neuritis  or  beri-beri. 

Morbid  Anatomy. — The  lesions  are  those  already  described  under  Local- 
ized Neuritis.  In  a  majority  of  the  cases  it  is  a  degenerative  process  not 
associated  with  much  connective-tissue  or  nuclear  proliferation,  and  no  super- 
ficial changes  may  be  observed.  The  alterations  are  invariably  more  marked 
at  the  peripheral  distribution  of  the  fibres  than  in  the  trunk.  The  medulla 
is  swollen,  fragmented,  and  granular,  and  in  extreme  cases  forms  a  molecular 
debris.  The  axis-cylinders  also  become  granular  and  subdivided,  and  finally 
all  trace  of  separation  between  the  two  essential  constituents  of  the  fibre 
becomes  lost  and  the  sheath  of  Schwann  alone  remains.  The  change  may 
exist  for  a  variable  extent  along  a  nerve,  and  may  not  be  contimious,  but 
interrupted.  The  nuclei  of  the  sheath  of  Schwann  in  many  cases  show  active 
proliferation,  and  they  probably  play  a  very  important  part  in  the  regenera- 
tion of  the  fibres.  In  other  cases  interstitial  changes  exist  with  the  parenchy- 
matous degeneration.  They  are  usually  much  more  marked  in  the  medium- 
sized  and  larger  nerve-trunks. 

Symptoms. — It  will  be  best,  perhaps,  to  describe  certain  well-character- 
ized types,  as  the  symptomatology  of  multiple  neuritis  is  extremely  complex. 

Acute  Febrile  Polyneuritis. — The  attack  may  begin  acutely  or  subacutely 
after  exposure  or  after  prolonged  exertion,  occasionally  during  convalescence 
from  an  infectious  disease.  The  affection  may  set  in  with  a  chill,  followed  by 
pain  in  the  ba(rk  and  limbs,  and  moderate  fever,  reaching  in  some  instances  to 
103°  F.  Headache,  loss  of  ajipetite,  and  the  general  features  of  an  acute 
infection  are,  as  a  rule,  present.  Pain,  numbness,  tingling,  or  hyperaesthesia 
is  felt  in  the  peripheral  parts.  Sometimes  the  pains  are  lancinating,  and  are 
usually  more  intense  in  the  legs  than  in  the  arms.  The  nerve-tnuiks  may  be 
painful  on  pressure,  particularly,  according  to  Leyden,  in  the  vicinity  of  the 
joints.  By  the  second  or  third  day  loss  of  power  is  noticed,  first  in  tiie  legs, 
chiefly  in  the  extensors,  and  in  the  course  of  a  few  days  it  extends,  reaches  the 
muscles  of  the  thighs,  attacks  the  arms,  and  within  a  week  there  may  be  wide- 
spread paralysis,  which  may  even  extend  to  tiie  muscles  of  the  thorax  and  to 
those  of  the  face.  The  muscles  may  rapidly  waste,  and  there  is  marked 
diminution  of  the  faradic  and  galvanic  contract ility.  The  rcfiexes,  as  a  ride, 
are  abolished.  Vaso-motor  changes  are  not  infrerpient,  such  as  congestion  of 
the  extremities  and  sweating.  The  clinical  picture  in  many  cases  is  that  of 
an  acute  ascending  paralysis.  In  the  most  intense  forms  death  niav  occur 
within  a  week  ;  more  commonly  not  until  the  thii-d  or  fi»iirth  week.  In  other 
instances  the  <Miset  is  more  subacute    and    the  disease  does  not    run  a   rapid 


808 


DISEASES    OF    THE   NERVES. 


course.  There  may  be  uo  fever,  very  little  pain,  and  the  gradual  loss  of 
power,  with  wasting,  may  give  a  picture  very  similar  to  the  subacute  spinal 
paralysis  of  Ducheune. 

Alcoholic  Neuritis. — This  form,  first  recognized  by  James  Jackson,  Sr.,  of 
Boston  in  1822,  is  the  commonest  type  of  the  disease.  It  appears  to  be  more 
frequent  in  women  than  in  men,  and  follows  prolonged  drinking,  either  of 
beer  or  of  spirits.  The  onset  is  marked,  as  a  rule,  by  sensory  symptoms, 
such  as  numbness  and  tingling  in  the  hands  and  feet,  and  not  infrequently 
painful  cramps  in  the  muscles.  These  symptoms  are  usually  regarded  as 
neuralgic,  and  the  nature  of  the  affection  for  a  time  is  overlooked.  There 
may  be  marked  sensitiveness  of  the  skin  ;  more  rarely  areas  of  anaesthesia. 
The  hands  and  feet  are  cold,  sometimes  a  little  swollen  ;  not  infrequently  there 
is  congestion  or  a  blotchy  redness,  rarely  nrticaria.  In  women  the  condition 
of  glossy  skin  is  sometimes  present  in  the  hands  and  feet.  Following  these 
sensory  symptoms,  paralysis  is  usually  noticed,  beginning  in  the  hands  and 
feet,  and  attacking,  as  a  rule,  the  extensors,  causing  foot-  and  wrist-drop.  (See 
Fig.  55.)     The  invasion  of  the  extremities  may  be  simultaneous  and  progres- 

FiG.  55. 


Multiple  Alcoholic  Neuritis:  palsy  of  extensors  of  wrist  and  flexors  of  ankle  (Gowers). 

sive,  and  in  a  few  instances  within  ten  or  twelve  days  there  may  be  complete 
paralysis  of  all  extremities,  and  occasionally  the  aiuscles  of  the  face,  and  even 
the  sphincter  muscles,  are  involved.  Death  may  be  caused  by  involvement 
of  the  muscles  of  respiration.  The  affected  muscles  are  soft,  waste  rapidly, 
and,  as  a  rule,  the  faradic  irritability  is  early  lost  and  the  galvanic  irritabil- 
ity is  decreased.  The  superficial  and  deep  reflexes  are  lost.  In  protracted 
cases  the  legs  may  be  strongly  flexed  on  the  thighs  and  deformities  produced 
in  the  feet ;  more  rarely  in  the  hands. 

The  cerebral  symptoms  of  alcoholic  neuritis  are  very  remarkable.  Convul- 
sions may  occur  even  at  the  onset  or  in  the  course  of  the  disease.  Mental 
symptoms  are  very  commonly  present — either  delirium,  Avhich  may  be  acute, 
or  halhicinations,  with  extravagant  ideas,  resembling  sometimes  those  of 
dementia  paralytica.  James  Ross,  who  has  specially  studied  the  psychical  dis- 
orders of  multiple  neuritis,  divides  tliem  into  four  stages  :  first,  a  premonitory 
stage,  in  which  the  special  senses  and  the  imaginative  faculties  are  exalted ; 
.second,  a  stage  of  depression  or  melancholia;  third,  a  transition  to  mania  or 
melancholia,  with  excitement,  or  of  convulsions,  passing  on  to,  fourth,  a  final 


-   /  NEURITIS.  809 

stage  of  dementia.  A  special  teuture  in  certain  instances  is  the  complete  loss 
of  appreciation  of  time  and  place,  and  a  patient  describes  lonu;  jonrneys  whicii 
he  has  taken  or  tells  of  interviews  which  he  has  had  with  individnals.  Eye- 
symptoms  are  rare,  thongh  there  may  be  a  remarkable  hazy,  tnrbiil  condition 
of  the  retina. 

Post-febrile  Neuritis — Under  the  various  infectious  disorders  mention  will 
be  made  of  the  forms  of  paralysis  liable  to  occur  during  convalescence,  u 
majority  of  which  are  now  known  to  be  due  to  involvement  of  tiie  peripheral 
nerves.  The  most  common  and  serious  is  the  diphtheritic  paralysis,  which 
may  be  local,  involving  the  nerves  of  the  palate,  eyes,  or  heart ;  or  general, 
involving  the  nerves  of  the  extremities.  Following  typhoid  fever,  small-pox, 
measles,  and  scarlet  fever,  a  neuritis  may  be  limited  to  the  nerves  of  the  leg, 
producing  a  para])legia,  or  in  some  instances  cause  widespread  loss  of  power 
and  rapid  wasting,  so  that  the  cases  are  very  often  regarded  as  acute  or  sub- 
acute myelitis.     In  rare  instances  neuritis  occurs  in  malaria. 

Some  of  the  most  characteristic  features  of  leprosy  are  due  to  invasion  of 
the  peripheral  nerves  by  the  bacillus  leprce,  a  neuritis  which  is  responsible  in 
great  part  for  the  trophic  changes  and  the  anesthesia. 

A  very  important  group  of  cases  of  neuritis  depends  upon  j)oisoning  by 
the  metals,  such  as  lead,  arsenic,  copper,  and  mercury.  Lead  palsy,  the  most 
common  form,  will  be  considered  with  Plumbism. 

Special  attention  has  been  directed  lately  to  the  paralysis  following  poison- 
ing by  coal-gas  from  furnaces  and  illuminating  gas.  The  effects  may  be  lim- 
ited to  certain  groups  of  nerves  or  may  be  widespread. 

The  cases  grouped  by  Ross  as  due  to  endogenous  poisons  j)robably  result 
fnjni  the  action  of  toxic  materials  produced  as  a  result  of  faulty  metab- 
olism. The  most  important  is  the  diabetic  neuritis.  Very  similar  is  the 
dyscrasic  group  of  cases  occurring  in  marasmus  and  the  cachexias  of  vari- 
ous diseases. 

Endemic  Neuritis  {Beri-beri). — In  China,  Japan,  parts  of  Africa,  and  in 
the  East  and  West  Indies  there  is  a  widespread  endemic  disease  which  has 
been  shown  by  Sheube  and  Baelz  to  be  a  peripheral  neuritis.  In  mild  cases 
there  is  slight  diificulty  in  walking,  associated  with  numbness,  pains  in  the 
legs,  and  oedema.  Antemia  is  often  present,  with  palpitation  of  the  heart  and 
general  malnutrition.  In  the  severer  cases  the  paralysis  is  more  extensive, 
and  involves  arms  and  legs,  and  even  the  trunk  and  face.  Wasting  proceeds 
rapidly  and  the  i)ati('nt  becomes  completely  helpless.  In  the  other  instances, 
known  as  the  "  wet  type  "  of  the  disease,  with  the  paralysis  there  is  great 
fedema  with  effusion  into  the  serous  sacs.  General  anasarca  may  completely 
cloak  the  nuiscular  atroi)hy.  And  lastly,  there  is  a  pernicious  form,  in  which 
the  nerve-phenomena  are  not  so  striking,  with  gastro-intestinal  symptoms, 
suppression  of  the  urine,  and  signs  of  greatly  enfeebled  circulation  ;  death 
mav  result  within  a  few  davs.  While  l)ut  little  (luiihl  exists  as  to  the  marked 
involvement  of  the  peripheral  nerves  in  beri-lxri,  tliere  is  the  greatest  discord 
as  to  the  exact  causation  of  the  disease:  some  attribute  it   to  ankylostomiasis; 


810  DISEASES    OF    THE  NERVES. 

others  to  the  eating  of  fish,  more  particularly,  according  to  Miura,  decomposed 
fish  ;  others,  again,  to  a  vegetable  diet,  particidarly  rice.  On  the  other  hand,  a 
micrococcus  has  been  isolated  from  the  disease,  and  cultures  are  stated  to 
induce  degeneration  in  the  nerves  in  inoculated  animals. 

Cases  of  multiple  neuritis  have  been  reported  by  J.  J.  Putnam  and  others 
among  the  New  England  fishermen  who  frequent  the  Grand  Banks.  The 
prominent  symptoms  are  oedema,  shortness  of  breath,  muscular  paralysis,  and 
sensory  disturbances.  The  paralysis  may  be  very  extensive  and  prove  fatal. 
Birge  has  reported  an  outbreak  in  one  vessel  with  a  crew  of  thirteen  sailors, 
eleven  of  whom  were  attacked,  two  cases  ending  fatally. 

Diagnosis. — In  the  majority  of  cases  of  multiple  neuritis  the  mode  of 
onset,  the  combination  of  sensory  and  motor  symptoms,  the  involvement  of 
the  distal  parts  of  the  extremities,  the  tenderness  of  the  nerve-trunks,  and  the 
wasting  and  sensitiveness  of  the  muscles,  suffice  to  render  the  diagnosis 
easy.  In  those  forms  which  rapidly  spread  and  involve  all  the  extremities 
the  diagnosis  from  acute  poliomyelitis  and  from  Landry's  paralysis  is  some- 
times difficult. 

In  anterior  poliomyelitis  the  febrile  onset,  the  rapid  paralysis  with  wasting, 
and  the  electrical  reactions  afford  no  differential  criteria.  The  sensory  symp- 
toms are,  however,  rarely  present,  and  in  multiple  neuritis  the  paralysis  is 
more  symmetrical  in  its  onset  and  as  a  rule  develops  more  slowly.  The  sen- 
sory phenomena  give  the  most  important  aid  in  the  diagnosis  of  multiple  neur- 
itis, and  when  these  are  only  transitory  or  present  in  a  slight  degree,  the  dif- 
ficulty may  be  very  great.  In  such  instances  the  subsequent  course  of  the 
disease  usually  affords  grounds  for  separation  ;  thus,  in  multiple  neuritis, 
although  the  atrophy  may  be  extreme  and  contractures  present,  recovery  in 
time  almost  invariably  occurs,  whereas  in  poliomyelitis,  though  many  of  the 
muscle-groups  may  gradually  recover,  others  remain  permanently  damaged.  In 
the  alcoholic  cases  the  mental  symptoms  already  described  are  very  character- 
istic. The  cases  described  by  Duchenne  under  the  term  subacute  diffuse  ante- 
rior spinal  paralysis  (paralysie  generale  spinale  anterieure  subaigue)  are  now 
usually  regarded  as  examples  of  polyneuritis.  They  occur  without  fever,  fol- 
lowing usually  the  infectious  disorders,  or  result  from  poisoning  by  arsenic  or 
lead.  The  sensory  symptoms  may  be  very  slight,  and  cases  are  on  record 
in  which  the  face  has  been  involved  and  also  the  sphincters.  Every  feature 
described  by  Duchenne  may  be  present  in  these  cases,  and  yet  the  general 
course  of  the  affection  and  the  ultimate  recovery  would  indicate  a  peripheral 
lesion.  In  a  case  under  Dejerine  at  the  Bicetre  the  first  attack  in  1880  came 
on  without  definite  cause,  and  involved  the  extremities,  the  muscles  of  the  eyes, 
the  lower  facial  muscles,  those  of  the  tongue,  and  of  the  pharynx.  After  per- 
sisting for  two  years  complete  recovery  took  place.  A  second  attack  followed, 
and  within  three  months  the  patient  was  completely  paralyzed,  and  there  were 
suffocative  attacks,  owing  to  the  involvement  of  the  muscles  of  the  pharynx 
and  larynx.  The  sensibility  was  unaffected.  The  reflexes  were  abolished  and 
there  was  diminution  of  the  contractility ;    gradual    recovery  took   place  in 


NEURITIS.  811 

about  fifteen  mouths.  The  distiuction  between  multiple  neuritis  and  Liuulry's 
paralysis  will  be  considered  under  the  latter  aU'eetion. 

The  etiological  factor  is  of  the  first  importance  in  the  diagnosis  of  many  of 
the  forms  of  polyneuritis,  particularly  those  occurring  in  alcoholics,  in  the  cases 
following  fevers,  and  in  those  du6  to  lead  and  arsenic. 

From  locomotor  ataxia  the  diagnosis  is  easy.  Unfortunately,  the  term  tabes 
has  been  applied  to  several  forms  of  partial  paraplegia  ^vhich  are  really  of 
neural  origin,  such  as  the  so-called  arsenical  tabes  and  diabetic  tabes,  or,  as 
some  call  it,  the  sensory  form  of  tabes.  The  pains  in  neuritis  rarely  have  the 
lightning-like  character,  there  is  sensitiveness  in  the  course  of  the  nerves,  and 
a  combination  of  paralysis  and  atrophy,  particularly  in  the  extensors  of  the 
feet  and  toes.  Romberg's  symptom  is  not  present,  the  inco-ordination  is 
slight  or  not  at  all  marked,  and  lastly  the  gait  is  entirely  different;  thus  in 
the  post-febrile  neuritis  and  in  the  form  due  to  lead  the  loss  of  power  in  the 
extensors  of  the  feet  and  toes  causes  the  leg  to  be  lifted  high  in  order  to  avoid 
the  catching  of  the  toes  in  consequence  of  the  foot-drop.  This  .steppage  gait, 
as  it  is  called  by  Charcot,  is  quite  distinctive  of  peripheral  neuritis,  and  is 
recognizable  at  a  glance  from  that  of  ataxia,  in  which  the  foot  is  thrown  up 
and  out  and  brought  down   in  a  stamping  manner. 

Prognosis. — Danger  to  life  exists  only  in  those  cases  in  which  the  paralysis 
extends  rapidly  and  involves  the  muscles  of  respiration.  In  such  instances 
death  has  occurred  as  early  as  the  sixth  day.  Death  occasionally  occurs  in 
alcoholic  polyneuritis,  and  more  frequently  from  complications  than  from  the 
disease  itself.  The  majority  of  cases  of  multiple  neuritis  of  all  forms  recover, 
though  it  may  be  months  before  power  is  regained  in  all  the  muscles.  Even 
with  an  extreme  grade  of  atrophy  with  contractures  it  is  n-markabh^  how  in 
time  recovery  may  take  ])lace. 

Treatment. — When  tiie  neuritis  is  widespread  the  ]>atient  is  more  comfort- 
able uj)()n  a  water-bed.  The  diet  should  be  light  and  nutritious,  and  in  the 
alcoholic  cases  special  care  must  be  exercised  that  the  patient  is  not  surrep- 
titiously given  beer  or  spirits.  The  fever  of  onset  rarely  demands  treatment. 
In  the  cases  following  cold  and  exposure  the  salicvlates  mav  be  tried.  For 
the  pains  in  the  joints  and  limbs  antifcbrin  or  antipyrine  may  be  given.  In 
some  instances  morphine  is  necessary.  Local  applications  are  often  very 
serviceable,  particularly  chloroform  liniment.  T]\o  thernio-cautcry,  lightly 
a])plicd  along  the  sensitive  nerve-trunks,  is  sometimes  of  the  greatest  service. 
As  the  patients  often  suffer  from  cold,  the  limbs  should  be  wrajiped  in  cotton- 
wool, and  it  is  advantageous  when  much  congestion  is  present  in  the  hands  to 
keep  them  slightly  raised  on  pilhiws.  After  the  acute  stage  has  jiasscd  arsenic 
and  strychnia  may  be  administered,  either  together  oi'  alternately.  Systematic 
massage  should  at  this  time  be  thoroughly  carried  out,  since  It  Is  probably  tlie 
most  serviceable  of  all  measures  in  the  paralysis  and  wasting  of  nnilti|)le  neur- 
itis. Electricitv  mav  be  applied  to  the  affected  nnis<'les,  one  pole  placed  over 
the  truid<  of  the  nerve,  and  the  other  over  the  nniscle.  The  slowly  interrupted 
current  is  the  best.     Care  must  be  taken  to  prevent,  if  possible,  contractures, 


812  DISEASES    OE    THE  NEBVES. 

and  when  they  exist  they  can  usually  with  patience  be  overcome  by  passive 
movements  and  systematic  rubbing. 

Neuroma. 

Properly  speaking,  this  term  should  be  applied  only  to  growths  containing 
nerve-substance,  but  it  is  applied  somewhat  indiscriminately  to  all  tumors  of 
the  nerves.  The  distinction,  however,  may  be  made  of  true  and  false  neuro- 
mata. The  true  contain  either  nerve-cells,  neuroma  celhdare,  or  nerve-fibres, 
which  may  be  either  medullated  or  non-medullatcd. 

The  neuroma  celhdare,  also  knowai  as  the  ganglionic  or  medullary  neuroma, 
is  an  extremely  rare  form  of  growth  met  with  occasionally  in  the  basal  ganglia 
and  in  other  parts  of  the  central  nervous  system,  more  rarely  attached  to  the 
auditory  or  olfactory  nerves.  Certain  forms  of  ueuroglioma  may  resemble  it 
very  closely. 

Tumors  containing  nerve-fibres  are  met  with  most  frequently  on  the  nerves 
of  the  skin  and  in  the  ends  of  the  nerves  in  amputation  stumps.  The  former 
constitute  the  small  painful  tumors  which  have  been  termed  tubercula  dolorosa, 
which  sometimes  occur  in  numbers  about  the  joints,  occasionally  in  the  skin 
of  the  face  or  on  the  scrotum.  Though  painful  to  the  touch,  particularly  at 
certain  seasons,  these  are  not  always  true  neuromata,  but  may  consist  of  firm 
connective  tissue,  and  sometimes  are  adenomata  of  the  sweat-glands. 

The  amputation  neuromata,  perhaps  the  most  common,  form  ovid  growths 
the  size  of  peas  or  beans  on  the  extremities  of  the  nerve-trunks  in  a  stump. 
They  are  made  up  of  connective  tissue  and  medullated  or  non-medullated 
nerve-fibres,  and  are  sometimes  extremely  painful.  Neuromata  are  occasion- 
ally met  with  on  the  nerves  of  the  cauda  equina  and  on  the  peripheral  nerve- 
trunks,  in  which  situation  thev  mav  be  felt  as  definite  bead-like  swellings. 

The  most  remarkable  variety  is  the  plexijorm  neuroma,  a  congenital  con- 
dition in  which  the  nerve-cords  in  various  parts  of  the  body  are  the  seat  of 
tumor  formations.  In  the  remarkable  case  described  by  Prudden,  the  speci- 
mens of  which  are  at  the  Medical  Museum  of  Columbia  College,  New  York, 
there  were  eleven  hundred  and  thirty-two  definite  tumors  on  the  various  nerves 
of  the  body. 

The  false  neuromata  consist  of  nodular  formations  of  connective  tisssue — 
fibroma,  more  rarely  myxoma,  sarcoma,  or  lipoma. 

There  may  be  no  symptoms  even  when  the  tun)ors  are  multiple.  In  other 
instances  there  is  pain,  which  is  often  referred  to  the  peripheral  distribution 
of  the  nerve.  The  subcutaneous,  painful  tumor  may  be  exquisitely  sensitive, 
and  when  in  a  situation  exposed  to  friction  or  to  knocks  exceedingly  trouble- 
some. The  amputation  neuromata  often  cause  great  pain  in  the  stump. 
Muscular  twitching  may  occur,  and  it  is  stated  that  in  some  instances 
epileptic  seizures  have  been  caused  by  them. 

When  painful  the  tumors  may  be  excised.  The  amputation  neuromata 
may  recur  after  excision. 


DISEASES    OF    THE    CRANIAL    XERVES.  813 

DISEASES   OF  THE  CRANIAL  NERVES. 

Affections  of  the  Olfactory  Nerve. 

Tlie  sense  of  suiell  uiay  be  lost  or  perverted,  rarely  inereased. 
Anosmia,  loss  of  the  sense  of  smell,  may  depend  upon — 

1.  Involvement  of  the  nerve-fibres  in  the  mueoiis  membrane.  This,  by 
far  the  most  common  eanse,  results  from  chronic  nasal  catarrh,  the  presence  of 
polypi,  and  occasionally  from  strong  irritants.  Paralysis  of  the  fifth  nerve 
mav  be  associated  with  loss  of  the  sense  of  smell,  owinir  to  disturbance  in  the 
secretion  and  absence  of  the  necessary  moisture. 

2.  Lesions  of  the  olfactory  nerve  and  bulb,  unilateral  or  bihiteral,  in  frac- 
ture of  the  skull,  caries,  local  meningitis,  and  tumors.  A  jirimary  atrophy 
of  the  nerve  is  stated  sometimes  to  occur  in  locomotor  ataxia. 

3.  The  loss  of  the  sense  of  smell  due  to  central  disease  is  less  common. 
The  centre  for  the  sense  of  smell  is  placed  by  Ferrier  in  th(>  uncinate  gyrus, 
and  in  a  few  instances  the  disturbance  or  loss  of  the  sense  lias  been  noticed  in 
connection  with  disease  of  this  part.  Occasionally  the  olfactory  nerves  and 
bulbs  are  congenitally  defective. 

Parosmia,  or  subjective  sensations  of  a  disagreeable  nature,  is  met  with 
most  frequently  in  hysterical  patients  and  in  the  insane.  In  epilepsy  the  aura 
may  be  olfactory  in  character,  and  the  patient  complains  of  an  unpleasant  odor, 
such  as  of  the  burning  of  rags,  paper,  or  feathers.  In  other  instances  the 
parosmia  exists  alone  in  an  apparently  healthy  individual :  Morell  Mackenzie 
mentions  the  case  of  a  lady,  aged  about  fifty,  to  whom  the  smell  of  cooked 
meat  was  so  exactlv  like  tiiat  of  stinking  fish  that  scarcely  anv  animal  food 
could  be  taken.  After  injury  to  the  head  the  perversion  of  the  smell  may 
persist  and  odors  of  the  most  different  character  )nay  appear  alike. 

Increased  sensitiveness,  or  hyperosmia,  is  a  rare  condition  met  with  occa- 
sionally in  hysterical  patients  and  in  insanity.  So  acute  may  the  sense  become 
that  individuals  may  be  recognized  by  the  odor  alone. 

The  sense  of  smell  may  be  tested  by  such  substances  as  cloves,  musk,  and 
peppermint.  In  routine  neurological  work  the  sense  should  be  testtnl  sys- 
tematically in  brain  cases,  and  it  can  readily  be  done  by  having  small  bottles 
filled  with  the  essential  oils.  A  careful  rhinosco|)ic  examination  should  be 
made  in  every  case,  as  the  disturbance  of  function  not  infrecpicntly  depends 
upon  peripheral,  not  central,  causes. 

Affections  of  the  Optic  Nerve. 
The  lesions  may  be  in  tiie  terminal  expansion   in   the  retina,  in  the  optic 
nerve,  at  the  chiasma,  in  the  optic  tract,  or  in  the  prolongation  of  the  fibres 
within  the  brain   and   in   the  cortical   centre  for  vision. 

I^ESIONB   or    THE    ReTFNA. 

(1)  Retixftis. — The  changes  in  the  retina  arc  of  the  greatest  importance 
in  diagnosis,  and  very  vahial>le  information  may  be  obtained  by  the  systematic 


814  DISEASES    OF    THE  NERVES. 

examination  of  this  membrane,  particularly  in  Bright's  disease,  leukaemia, 
ansemia,  and  syphilis.  The  chief  changes  are  a  cloudiness  or  turbidity  due 
to  the  eft'usion  of  serum  in  the  layers  of  the  retina,  haemorrhages,  which  are  in 
the  layer  of  nerve-fibres  and  often  follow  the  course  of  the  vessels,  and  white 
spots  or  opacities.  The  haemorrhages  and  opacities  are  the  features  commonly 
regarded  as  indicative  of  retinitis.  When  fresh  they  are  bright  red  in  color, 
but  the  effused  blood  gradually  undergoes  changes,  and  ultimately  the  spots 
become  quite  black.  The  opacities  are  due  to  inflammatory  exudation,  to  fatty 
degeneration,  or  to  sclerotic  change. 

The  white  spots  also  occur  on  the  choroid  as  a  result  of  atrophy  of  the  pig- 
ment or  the  presence  of  new  formations,  particularly  tubercles.  Large  areas 
of  atrophy  of  pigment  occur  in  certain  cases  of  congenital  syphilis.  Tuber- 
cles in  the  choroid  will  be  referred  to  in  the  section  on  Tuberculous  Meningitis. 
The  following  are  the  more  important  forms  : 

Albuminuric  Retinitis. — In  chronic  nephritis,  particularly  the  interstitial 
form,  a  variable  number  of  the  cases — 15  to  20  per  cent. — present  retinal 
changes.  As  disturbance  of  vision  may  be  an  early  symptom,  the  diagnosis 
of  Bright's  disease  is  very  frequently  made  by  the  oculist.  The  retinal  arte- 
ries may  be  very  small,  and  may  be  bordered  by  white  lines,  the  result  prob- 
ably of  perivascular  changes.  Small  aneurismal  dilatations  may  sometimes 
be  seen.  Gowers  recognizes  two  forms  of  albuminuric  retinitis — degenerative 
and  inflammatory.  The  degenerative  variety  is  characterized  by  small  whitish 
spots,  either  punctiform  or  elongated,  which  are  most  abundant  about  the 
macula.  Linear  and  flame-shaped  haemorrhages  occur,  and  sometimes  a  diffiise 
opacity.  In  the  inflammatory  form  there  is  much  swelling  of  the  retina  and 
the  arteries  are  obscured.     Haemorrhages  are  numerous. 

There  is  a  group  of  cases  met  with  both  in  arterio-sclerosis  and  in  chronic 
Bright's  disease  in  which  the  optic  nerve  is  chiefly  involved,  the  disk  being 
greatly  swollen  and  striated,  the  vessels  obscured,  while  the  retina  is  either 
slightly  involved  or  also  presents  haemorrhages  and  signs  of  intense  retinitis. 
When,  as  sometimes  happens,  this  condition  is  associated  with  headache  and 
transient  aphasia,  the  diagnosis  from  brain  tumor  is  very  difficult.  Among 
the  complications  of  albuminuric  retinitis  may  be  mentioned  haemorrhage  into 
the  choroid,  detachment  of  the  retina,  haemorrhage  into  the  vitreous,  and  em- 
bolism of  the  central  artery. 

A  retinitis  not  unlike  that  of  albuminuria  also  occurs  in  diabetes.  In 
profound  anaemia,  in  whatever  way  produced,  retinal  changes  are  common, 
chiefly  in  the  form  of  haemorrhages,  more  rarely  as  a  neuro-retinitis.  They 
occur  particularly  in  pernicious  anaemia,  occasionally  in  chlorosis,  in  which  the 
condition  is  more  commonly  a  neuritis,  and  in  malarial  cachexia. 

Leukcemic  Retinitis. — A  remarkable  form  occurs  in  leukaemia,  usually  in 
the  splenic  variety.  There  may  be  onl}'  a  diffuse  thickening  and  infiltration, 
with  turbidity  of  the  membrane  or  extensive  haemorrhage,  but  the  most  dis- 
tinctive form  is  characterized  by  the  presence  of  opaque  white  or  yellowish- 
white  spots,  which  may  even  resemble  little  tumors.     So  characteristic  is  this 


AFFECTIONS    OF    THE    OPTIC  NERVE.  815 

condition  that  the  diagno.sis  has  been  suggested  by  the  ophthahnoseopic  exam- 
ination alone. 

Haemorrhages  are  also  met  with  in  jiurpura,  scurvy,  an<l  in  chronic  lead- 
poisoning,  and  sometimes  in  association  with  suppression  of  the  menses,  more 
rarely  M'ith  pregnancy. 

(2)  Functional  Disturbance  of  the  Retina. —  To.vic  Amaurosis. — 
In  chronic  Bright's  disease  sudden  blindness  may  develop,  and  persist  for 
some  time  without  tlie  existence  of  any  retinal  chanues.  This,  known  as 
ui-remic  amaurosis,  is  not  necessarily  associated  with  other  tt)xic  phenomena, 
and  is  usually  a  transient  condition. 

In  cases  of  acute  saturnism  a  similar  amaurosis  has  been  described.  Toxic 
doses  of  quinine  occasionally  cause  amaurosis.  The  amount,  according  to 
Gowers,  which  has  caused  the  symptom  has  varied  from  the  minimum  of  80 
grains  in  thirty  hours  to  1300  grains  in  three  days.  It  is  usually  accompanied 
with  loss  of  hearing.  Recovery  as  a  rule  occurs,  though  it  may  be  months 
before  the  vision  is  normal. 

Tobacco  amaurosis  comes  on  slowly  in  both  eyes,  and  presents  a  very  cha- 
racteristic effect  in  the  centre  of  the  field  of  vision — usually  only  dimness,  not 
an  actual  loss  of  sight.  The  central  defect  or  scotoma  is  nuich  greater  for  colors. 
In  a  few  instances  the  optic  nerve  has  been  involved  and  atrophy  has  developed. 

Hysterical  amaurosis  may  be  complete,  hut  more  (lommonly  involves  only 
half  the  fields,  causing  hemianopia.  The  condition  is  usually  transient,  but 
may  ])ersist  for  months  or  even  for  years.  In  many  cases  there  is  marked 
restriction  of  the  visual  fields.  Among  other  functional  disturbances  of  the 
retina  may  be  mentioned  night-blindness  (nyctaloj)ia),  a  condition  in  which 
objects  are  clearly  seen  during  the  day,  but  become  invisible  in  the  shade  or 
in  twilight;  and  hcmeralo])ia,  in  which  objects  can  not  be  well  seen  in  day- 
light or  in  strong  artificial  light.  Hyperesthesia  of  the  retina  is  met  with 
sometimes  in  hysteria,  but  is  not  a  common  symptom  in  inflammatory  or 
degenerative  conditions  of  the  membrane.  It  may  occur  in  connection  with 
the  intense  throbbing  of  the  retinal  arteries  in  aortic  insufficiency. 

Lesions  of  the  Optic  Nerve. 

Optic  Neuritis  (Papillitis). —  In  the  early  stage  the  edge  of  the  disk 
is  blurred  ar.d  the  rosy  tint  of  the  surface  increased.  Gradually  swelling  and 
opacity  become  evident,  the  physiological  cui)ping  disa])pears,  there  is  marked 
striation,  and  hiemorrhages  are  present.  The  arteries  may  at  first  jiresent  very 
slight  change,  but  later  are  narrow  and  the  veins  enlarged  and  <'ongestcd. 
Very  often  the  retina  is  simultaneously  involved — neuro-retinitis.  In  mild 
grades  the  swelling  of  the  disk  gradually  subsides  and  recovery  may  take 
place  with  but  little  damage.  In  other  instances  the  swelling  and  exudation  ^ 
are  very  great,  so  that  the  disk  is  |)romincnt  and  lai-gc,  with  marginal  stria- 
tion, lijcmorrhagcs,  and  i)atches  of  inflannnatory  exudation.  Willi  the  grad- 
ual subsidence  of  the  swelling  th«'  nerve-elements  undergo  atrophy,  and  thei-c 
is  finally  left  the  small   pearly  blue-whil(!  <lisk   (»f  optic  a(r(»|)hy.      The   iicur- 


816  DISEASES    OF    THE  NERVES. 

itis  may  be  chiefly  retro-ocular,  in  which  case  the  changes  may  be  very  slight 
at  the  papilla.  In  a  variety  of  this  form  known  as  axial  neuritis  the  central 
fibres  of  the  nerve  are  chiefly  involved. 

Optic  neuritis  occurs  most  frequently  in  connection  Avith  intracranial  dis- 
ease, particularly  tumors,  more  rarely  in  abscess.  In  a  great  njajority  of  the 
cases  it  is  bilateral.  It  is  met  with  also  in  meningitis  of  the  base,  both  simple 
and  tuberculous.  It  occurs  also  in  lead-poisoning,  in  anaemia,  in  chronic 
Bright's  disease,  usually  as  a  neuro-retinitis,  and  there  are  cases  known  as  idio- 
pathic in  which  no  etiological  factors  can  be  determined.  A  neuritis  of  an 
extreme  grade  may  be  present  with  very  slight  disturbance  of  vision,  but 
gradually  there  is  diminution  of  sight,  which  in  the  severe  cases  goes  on  to 
complete  and  permanent  blindness. 

The  relation  of  optic  neuritis  to  cerebral  disease  has  been  much  discussed. 
It  was  formerly  supposed  that  the  swelling  and  haemorrhage  of  the  disk  were 
largely  due  to  increased  intracranial  pressure  and  obstructed  return  of  blood 
from  the  eye.  The  term  "  choked  disk,"  or  Stauunffs-jjapille,  is  an  expression 
of  this  mechanical  theory.  Others  think  that  the  condition  is  produced  by 
distension  of  the  subvaginal  space  around  the  optic  nerve,  which  has  been 
shown  to  be  continuous  with,  and  can  be  injected  from,  the  subdural  space. 
A  majority  of  observers  now  hold  that  the  papillitis  is  always  the  result 
of  a  descending  neuritis,  the  inflammation  travelling  down  the  course  of  the 
nerve-fibres.  On  no  other  theory,  as  Stephen  Mackenzie  has  stated,  can  we 
explain  the  unilateral  neuritis  on  the  side  opposite  to  a  cerebral  growth. 

Optic  Atrophy. — Following  the  papillitis,  this  is  known  as  consecutive 
atrophy.  Primary  atrophy  is  met  with  in  some  instances  as  a  remarkable 
hereditary  affection  which,  as  in  Leber's  case,  aifected  all  the  males  in  a  fam- 
ily shortly  after  puberty.  A  majority  of  the  cases  occur  in  connection  with 
spinal  disease,  more  particularly  with  locomotor  ataxia,  more  rarely  in  general 
paresis  of  the  insane,  and  in  lateral  sclerosis.  O^'casional  causes  are  sexual 
excesses,  migraine,  syphilis,  diabetes,  and  possibly  tobacco,  alcohol,  and  lead. 
The  ophthalmoscopic  appearances  are  different  in  the  cases  of  primary  and 
secondary  atrophy.  In  the  former  the  edges  of  the  disk  are  well  defined,  the 
tint  is  of  a  steel-gray,  tlie  physiological  cup  is  present,  and  the  arteries  look 
almost  normal.  In  the  consecutive  atrophy  the  disk  has  a  staring,  opaque- 
white  aspect,  the  outlines  are  often  irregular,  and  the  arteries  are  small. 

The  loss  of  sight  in  optic  atrophy  may  vary  from  a  very  slight  degree  to 
complete  blindness.  Gradual  contraction  of  the  fields  of  vision  takes  place, 
and  in  a  majority  of  the  cases  the  color  perception  is  altered.  The  primary 
defect  as  a  rule  is  for  green  and  red.  In  the  cases  in  which  there  is  a  central 
scotoma  it  has  been  shown  that  the  neuritis  is  axial. 

The  prognosis  in  optic  atrophy  is  bad,  particularly  in  the  primary  form. 
In  the  form  following  neuritis  some  vision  is  more  commonly  retained. 

Lesions  of  the  Chi  asm  a  and  Tract. 
At  the  commissure  or  chiasma  the  optic  nerves  undergo  a  partial  decussa- 


AFFECTIOXS    OF    THE    CHI  ASM  A    AND    TRACT.  817 


FiQ.  5G. 


L     T.r. 


R.  N.  P 


L.O.S 


Diagram  of  Visual  Paths,  designed  to  illustrate  specially  left  lateral  hemianopsia  from  any  lesion  :  L.  T.  F., 
left  temporal  half-field  ;  It.  N.  F.,  right  nasal  half-field  ;  0.  5>.,  oculus  sinister;  0.  l>.,  oculus  dexter; 
N.  T.,  nasal  and  temporal  halves  of  retina' ;  J\'.  0.  >.,  nervus  oi)tious  sinister ;  N.  O.  I).,  nerviis  opticus 
dexter;  F.  C.  S.,  fasciculus  cruciatus  sinister;  F.  L.  I).,  fasciculus  lateralis  dexter;  ('.,  chiasina,  or 
decussation  of  fasciculi  cruciati ;  T.  0.  />.,  tractus  opticus  dexter;  C.  (1.  A.,  ciir))iis  gciiiculatum  lat- 
erale;  A.  O.,  lobi  ofjlici  (corpus  quad.) ;  P.  O.  C,  primary  optic  centres,  including  lol)\is  ojyiicus  eorp. 
genie,  lat.  and  pul vinar  of  one  side ;  F.  O.,  fasciculus  opticus  (Gratiolel)  in  the  internal  capsule ;  C.  P., 
cornu  po.sterior;  G.  A.,  region  of  gyrus  angnlaris  ;  L.  O.  S.,  lobus  occip.  sinister;  A.  O.  J).,  lobus  occip. 
dexter;  C"u.,  cuneus  and  subjacent  gyri,  constituting  the  cortical  visual  centre  in  man.  (The  heavy 
or  shaded  lines  represent  parts  connected  witli  the  right  halves  of  liotli  retin;f.)  (Scguin.) 


tion.  Each  tract  contain.s  ncrvc-fibrcs  wliicli  supply  (lie  (ciiiporal  li:iir  of  the 
retina  on  the  same  side  ami  the  nasal  li.ill'  '•("  the  opiiositc.  'Plic  nasal  or 
(locnssating  fibres  are  more  numerous  ami  (Mciipy  (Ik-  midtllc  pardon  of  fho 
chiasma. 

Lesion  of  one  tract  ean.ses  lu.^s  ot"  I'liiiftitjii   in   thr   (<iiipi)rai    iiall"  of"  tiie 

Vol.  I.— 52 


818  DISEASES    OF    THE   NERVES. 

retina  on  the  same  side  and  the  nasal  half  of  the  retina  on  the  other.  If,  for 
example,  the  right  tract  be  involved,  the  patient  has  only  half  vision  and  is 
blind  to  objects  on  the  left  side.  (See  Fig.  56.)  This  condition  is  termed 
lateral  or  homonymous  hemianopia.  The  hemianopia  may  be  partial,  only 
a  section  of  the  half  field  being  lost. 

Lesions  of  the  Chiasma. — If  the  central  portion  alone  is  involved,  in 
which  the  decussating  fibres  pass  to  the  inner  or  nasal  halves  of  the  retinae, 
there  is  loss  of  vision  in  the  outer  or  temporal  halves  of  the  visual  fields — 
temporal  hemianopia. 

A  lesion  limited  to  the  outer  part  of  the  chiasma  involves  the  direct  fibres 
passing  to  the  temporal  half  of  the  retina  and  causes  blindness  in  the  nasal 
field.  If  on  both  sides,  there  is  bilateral  nasal  hemianopia.  In  a  ])rogressive 
lesion  of  the  chiasma  the  different  stages  may  often  be  traced  from  temporal 
hemianopia  in  one  eye,  then  total  blindness  of  that  eye,  then  involvement  of 
the  fibres  passing  to  the  nasal  side  of  the  retina  of  the  other  eye,  producing 
temporal  hemianopia.  and  finally  complete  blindness. 

When  the  left  half  of  one  field  and  the  right  half  of  another,  or  vice  versd, 
is  blind,  the  condition  produced  is  known  as  heteronymous  hemianopia,  in  con- 
tradistinction to  the  homonvmous,  in  which  the  blindness  is  in  fields  of  the 
same  side. 

The  accompanying  figure  illustrates  the  different  forms  of  blindness  result- 
ing from  involvement  of  the  chiasma  and  tract. 

Centeal  Lesions  of  the  Tract  and  Optic  Nerve-fibres. — The 
tract  divides  at  the  hinder  part  of  the  optic  thalamus,  the  larger  portion  enter- 
ing the  thalamus,  the  external  geniculate  body,  and  the  anterior  quadrigeminal 
body,  from  which  fibres  enter  the  occipital  lobe  through  the  hinder  part  of  the 
internal  capsule,  forming  the  optic  radiation  which  terminates  in  and  about  the 
cuneus.  The  fibres  of  the  inner  division  of  the  tract  pass  to  the  internal  genic- 
ulate body  and  to  the  posterior  quadrigeminal  body. 

A  lesion  anywhere  between  the  cortical  centre  and  the  chiasma  will  pro- 
duce lateral  hemianopia.  The  lesion  may  be  situated  either  in  the  tract  itself, 
in  the  region  of  the  thalamus,  in  which  case  it  is  likely  to  be  associated  with 
hemiansesthesia  (from  involvement  of  the  sensory  tract  in  the  hinder  part  of 
internal  capsule)  and  sometimes  with  hemiplegia,  or  it  may  be  in  the  fibres 
of  the  optic  radiation  within  the  occipital  lobe;  and,  finally,  at  the  centre  in 
the  occipital  lobe  in  the  neighborhood  of  the  cuneus.  It  is  possible  that  the 
<liiferent  sections  of  the  retina  may  be  represented  in  diflPerent  regions  of  the 
cuneus. 

Color-vision  is  usually  lost  in  the  half  field — hemiachromatopia — but  in 
centval  disease  the  half  field  for  color  may  be  lost,  while  the  field  for  white  is 
intact. 

The  Significance  of  Hemianopia. — It  is  frequently  a  functional  trouble,  as 
in  migraine  and  hysteria.  In  about  half  the  cases  there  is  hemiplegia,  in  some 
instances  hemiansesthesia  and  aphasia.  It  is  of  great  importance  to  determine, 
if  possible,  whether  the  lesion  is  in  the  optic  tract  alone  or  at  the  centres.    This 


AFFECTIONS    OF    THE   MOTOR    NERVES    OF    THE  EYE.     ,S1<I 

can  occasionally  be  clone  by  a  test  devised  by  Wernicke,  known  as  the  hemiopic 
pupillary  inaction.  The  rcHex  arc  concerned  in  the  contraction  of  the  pti[)il 
consists  of  (1 )  the  optic  nerve-fibres,  wiiich  receive  and  transmit  the  impression, 
(2)  the  nerve-centre  in  the  geniculate  bodies,  whicii  receives  it  and  transmits  it  to 
the  fibres  of  (3)  the  third  nerve,  along  which  the  motor  impulses  pass  to  the  iris. 
Tiie  integrity  of  this  reflex  arc  is  demonstrated  by  the  contraction  of  the  pupil 
when  a  bright  light  is  thrown  into  the  eye.  In  a  case  of  lateral  hemianopia 
the  pencil  of  light  may  be  so  directed  that  it  falls  on  the  blind  half,  in  which 
case,  if  the  pui)il  react,  the  reflex  arc  above  mentioned  must  be  perfect ;  that 
is  to  say,  there  can  be  no  interruption  between  the  retina,  the  centre  in  the 
geniculate  bodies,  and  the  third  nerve.  In  such  a  case  the  conclusion  \i?  justi- 
fiable that  the  lesion  causing  the  hemianopia  is  situated  behind  the  geniculate 
bodies,  either  in  the  fibres  of  the  optic  radiation  or  in  the  cortical  centre.  On 
the  other  hand,  if  when  a  light  is  thrown  upon  the  hemianopic  half  of  the 
retina  the  pupil  remains  inactive,  the  conclusion  is  justifiable  that  the  path 
between  the  retina  and  the  geniculate  bodies  is  interrupted  and  the  lesion 
causing  the  hemianopia  is  not  central.  Wernicke's  test  is  not  always  easy  to 
obtain.  Seguin  gives  the  following  directions  :  "  The  patient  being  in  a  dark 
or  nearly  dark  room  with  the  lamp  or  gas-light  behind  his  head  in  the  usual 
position,  I  bid  him  look  over  to  the  other  side  of  the  room,  so  as  to  exclude 
accommodative  iris  movements  (which  are  not  necessarily  associated  with  the 
reflex).  Then  I  throw  a  faint  light  from  a  plane  mirror  or  from  a  large  con- 
cave mirror  held  well  out  of  focus  upon  the  eye,  and  note  the  size  of  the  pupil. 
With  my  other  hand  I  now  throw  a  beam  of  light,  focused  from  the  lamp  by 
an  ophthalmoscopic  mirror,  directly  into  the  optical  centre  of  the  eye,  then 
laterally  in  various  positions,  and  also  from  above  and  below  the  equator  of 
the  eye,  noting  the  reaction  at  all  angles  of  incidence  of  the  ray  of  light." 

Affections  of  the  Motor  Nerves  of  the  Eye. 

Third  Nerve. 

This  arises  from  a  centre  in  the  floor  of  the  aqueduct  of  Sylvius,  and,  j)ass- 
ing  forward  through  the  cms,  at  the  side  of  which  it  emerges,  it  enters  the 
orbit  through  the  sphenoidal  fissure,  and  supplies,  by  its  superior  branch,  the 
levator  palpebrse  superioris  and  the  superior  rectus,  and  by  its  inferior  branch 
the  internal  and  inferior  recti  and  the  inferior  oblique  muscles.  It  also  sup- 
j)lies  the  ciliary  muscle  and  the  constrictor  of  the  iris. 

Lesions  of  this  nerve  are  of  s])ecial  importance  in  the  diagnosis  of  disorders 
of  the  brain  and  si)inal  cord.  The  affections  may  be  cither  of  the  centre  or  of 
the  nerve  in  its  course,  and  may  cau.se  either  paralysis  or  spasm. 

Paralysis. — A  lesion  of  the  nuelcus  may  involve  the  centres  for  the 
other  eye-muscles,  causing  gcnci-.il  opIitliMlinoplcgia,  in  which  the  power  of 
movement  of  both  the  external  and  internal  musc^Ies  of  the  eyeball  is  lost. 
The  portion  of  the  nucleiis  j)residing  over  the  iris  may  i)e  involved  alone,  as 
in    locomotor  ataxia,  causing  loss  of  the  reflex — tUo  Argyll-lloberlson  i)iipil. 


820  DISEASES    OF    THE   NERVES. 

Much  more  frequently  the  nerve-trunk  is  involved  in  its  course,  either  com- 
pressed in  the  exudation  of  meningitis  by  a  gumma  or  an  aneurism,  lesions 
which  may  involve  it  either  at  the  crus  or  where  it  enters  the  sphenoidal  fis- 
sure. The  nerve  may  be  attacked  by  a  neuritis,  as  in  diphtheria  and  locomo- 
tor ataxia. 

The  following  symptoms  accompany  complete  paralysis  of  the  nerve :  loss 
of  power  in  all  the  muscles  of  the  eye  except  the  superior  oblique  and  the 
external  rectus ;  the  eye  cannot  be  moved  in  any  direction  except  outward 
and  a  little  downward  and  inward  ;  there  is  an  external  squint,  owing  to  the 
unopposed  action  of  the  external  rectus  ;  the  eyelid  droops — ptosis — owing 
to  paralysis  of  the  levator  palpebrse ;  the  iris  does  not  contract  to  light,  the 
power  of  accommodation  is  lost,  and  the  pupil  is  of  medium  size.  The  most 
striking  features  are  the  external  strabismus,  the  double  vision,  and  the  ptosis. 
The  aifection  of  the  nerve  may  be  partial ;  thus  paralysis  may  aifect  the 
branches  passing  to  the  superior,  inferior,  and  internal  recti  muscles.  The 
ciliary  branches  may  be  alone  attaciked,  causing  loss  of  the  power  of  accommo- 
dation and  paralysis  of  the  iris. 

Recurrent  Paralysis  of  the  Third  Nerve. — There  is  a  remarkable 
affection,  met  with  chiefly  in  women,  in  which  at  intervals  of  a  month  or  more 
the  oculo-motor  nerves  are  paralyzed.  It  may  begin  in  early  childhood,  and 
has  been  known  to  continue  for  many  years,  the  attacks  occurring  at  longer  or 
shorter  intervals  and  lasting  two  or  three  days.  They  have  been  associated 
with  headache  and  vomiting  and  symptoms  resembling  migraine.  Twenty- 
three  cases  have  been  collected  by  Mary  Sherwood  from  the  literature. 

Certain  special  features  of  third-nerve  paralysis  may  here  be  considered  : 

Ptosis. — This  common  and  important  symptom  occurs  under  the  following 
conditions  :  (1)  As  a  congenital  defect  which  is  sometimes  hereditary  and  met 
with  in  many  members  of  the  same  family.  (2)  From  lesion  of  the  third 
nerve,  either  at  its  nucleus  or  in  its  course.  This  may  be  associated  with 
paralysis  of  the  suj^erior  rectus  or  with  the  general  features  of  third-nerve 
paralysis  already  mentioned.  (3)  There  are  instances  in  which  with  cerebral 
lesions  the  ptosis  occurs  alone,  but  the  cortical  centre  has  not  yet  been  deter- 
mined. (4)  Hysterical  ptosis  is  occasionally  met  with,  and  is  readily  recog- 
nized by  its  association  with  other  hysterical  manifestations.  (5)  Sympathetic 
or  pseudo-ptosis  is  seen  in  paralysis  of  the  cervical  sympathetic,  and  appears  to 
be  due  to  loss  of  power  in  the  fibres  of  Miiller,  which  are  innervated  by  the 
sympathetic  and  assist  in  keeping  the  upper  lid  in  its  proper  position.  With 
this  form  there  are  symptoms  of  vaso-motor  disturbance,  such  as  unilateral 
sweating,  contraction  of  the  pu])il  on  the  same  side,  and  slight  retraction  of  the 
eyeball.  (6)  In  the  facio-scapulo-huraeral  type  of  muscular  atrophy,  in  which 
the  facial  nuiscles  are  affected,  there  may  be  bilateral  ptosis.  (7)  And  lastly 
there  is  a  transient  ptosis  sometimes  met  with  in  delicate  or  neurasthenic 
women,  particularly  in  the  early  morning  hours.  In  exaggerated  cases  there 
may  be  great  difficulty  in  lifting  the  eyelids.  This  is  sometimes  known  as 
"  morning"  ptosis. 


AFFECTIOXS    OF    THE   MOTOIi    yERVES    OF    THE  EYE.     821 

V 

The  symptoms  of  the  greatest  importance  in  third-nerve  paralysis  relate  to 
the  involvement  of  the  ciliary  muscle  and  iris. 

Cycloplegia — paralysis  of  the  ciliary  muscle — causes  loss  of  the  power  of 
accommodation,  in  consequence  of  which  near  objects  cannot  be  clearly  seen. 
It  may  be  present  in  one  or  in  both  eyes.  It  is  most  commonly  a  symptom 
of  nuclear  disease,  and  is  seen  in  diphtheria  and  in  locomotor  ataxia.  It  is  of 
special  value  in  the  diagnosis  of  tliphthcritic  paralysis,  in  which  it  occurs  with 
frequency  and  as  a  rule  early. 

Paralysis  of  the  Iris. — Iridoplegia. — (1)  Accommodative  Irkloplegia. — 
In  this  the  pupil  does  not  diminish  in  size  during  the  act  of  accommodation. 
To  test  it  the  patient  should  first  look  at  a  distant  and  then  at  a  near  object  in 
the  same  line.  Normally  under  these  conditions  the  pupil  contracts  during  the 
act  of  accommodation. 

(2)  Reflex  Iridoplegia. — The  path  for  the  iris  reflex  is  by  the  optic  nerve 
and  tract  to  the  geniculate  bodies,  and  then  to  the  oculo-motor  nucleus,  along 
the  trunk  of  the  third  nerve  to  the  ciliary  ganglia,  and  through  the  ciliary 
nerves  to  the  iris.  The  eyes  should  be  tested  separately,  and  it  is  perhaps  best 
to  use  an  artificial  light.  The  patient  looks  at  a  distant  object  in  a  dark  room, 
so  as  to  relax  the  accommodation  completely  ;  then  a  light  is  held  at  a  distance 
of  about  four  feet,  and  the  state  of  the  pupil  is  carefully  watciied.  IjOss  of 
the  iris  reflex  with  retention  of  contraction  on  accommodation  is  known  as  the 
Argyll-Robertson  pupil. 

(3)  Loss  of  the  Skin  Reflex. — Irritation  of  the  skin,  particularly  that  of 
the  neck,  is  followed  by  dilatation  of  the  pupil.  As  P>b  has  shown,  this 
skin    reflex  is  usually,  but  not  necessarily,  lost  with  the  reflex  contraction. 

Iridoplegia  is  usually  associated  with  small  pupils ;  thus  in  locomotor 
ataxia  the  pupils  are  often  much  contracted — spinal  myosis. 

Inequality  of  the  pupils — anisocoria — is  met  with  not  infrequently  in  gen- 
eral paralysis  of  the  insane  and  in  locomotor  ataxia.  It  also  occurs  in  healthy 
persons,  and  may  persist  for  years. 

Fourth  Nerve. 
The  nucleus  of  this  nerve  is  situated  in  the  upper  part  of  the  floor  of  the 
fourth  ventricle.  Coursing  around  the  cms  in  its  passage  to  the  orbit,  it  is 
liable  to  be  involved  in  tumors,  in  the  exudation  of  basilar  meningitis,  and 
niav  be  compressed  by  aneurism.  It  supj)lies  the  superior  obli(iue  muscle. 
Nuclear  paralysis  is  seen  in  connection  with  involvement  of  the  centres  of  the 
other  eye-muscles.  ]*aralvsis  of  the  suj)erior  oblique  causes  defective  down- 
ward and  inward  movement  of  the  eyeball.  There  is  double  vision  when 
the  patient  looks  downward,  which  is  obviated  when  the  patient  inclines  the 
head  forward  and  toward  the  sound  side,  'fhe  ])aralysis  may  lie  too  slight  to 
be  noticed. 

Six  III   Nkiivk. 

Arising  from  its  nucleus  in  the  floor  (»f  the  fourth  ventricle,  i(  passes  forward 
through  the  pons  and  emerges  at  the  junction  of  the  pons  and  medulla.    Enter- 


822  DISEASES    OF    THE   NERVES. 

ing  the  orbit,  it  supplies  the  external  rectus.  The  nerve  is  apt  to  be  involved  in 
tumors  and  meningeal  morbid  processes,  and  it  is  stated  also  to  be  sometimes 
paralyzed  by  cold.  Paralysis  of  this  nerve  causes  internal  strabismus,  and 
there  is  double  vision  on  looking  toward  the  paralyzed  side.  The  defect  in 
lesion  of  the  nucleus  is  thus  clearly  and  briefly  described  by  Beevor :  "  When 
the  nucleus  is  affected  there  is,  in  addition  to  paralysis  of  the  external  rectus, 
inability  of  the  internal  rectus  of  the  opposite  eye  to  turn  that  eye  inward. 
As  a  consequence  of  this  the  axes  of  the  eyes  are  kept  parallel,  and  both  are 
conjugately  deviated  to  the  opposite  side,  away  from  the  side  of  the  lesion. 
The  reason  of  this  is  that  the  nucleus  of  the  sixth  nerve  sends  fibres  up  in  the 
pons  to  that  jnirt  of  the  nucleus  of  the  opposite  third  nerve  which  supplies  the 
internal  rectus :  we  thus  have  paralysis  of  the  internal  rectus  without  the 
nucleus  of  the  third  nerve  being  involved,  owing  to  its  receiving  its  nervous 
impulses  for  parallel  movement  from  the  sixth  nucleus  of  the  opposite  side. 
As  the  sixth  nucleus  is  in  such  close  proximity  to  the  facial  nerve  in  the  sub- 
stance of  the  pons,  it  is  frequently  found  that  the  whole  of  the  face  on  the 
same  side  is  paralyzed,  and  gives  the  electrical  reaction  of  degeneration,  so 
that  with  a  lesion  of  the  left  sixth  nucleus  there  is  conjugate  deviation  of  both 
eyes  to  the  rigid — i.  e.  paralysis  of  the  left  external  and  the  right  internal  rec- 
tus, and  sometimes  complete  paralysis  of  the  left  side  of  the  face." 

General  Features  of  Paralysis  of  the  Motor  Nerves  of  the  Eye. — Gowers 
recognizes  five  groups  of  symptoms  : 

1.  Limitation  of  Movement,  which  is  in  proportion  to  the  grade  of  the  par- 
alysis. 

2.  Strabismus. — In  consequence  of  the  paralysis  the  axes  of  the  eyes  do 
not  correspond.  Paralysis  of  the  internal  rectus  causes  a  divergent  squint — 
of  the  external  rectus,  a  convergent  squint.  The  deviation  of  the  axis  of  the 
aifected  eye  from  parallelism  with  the  other  is  known  as  the  primary 
deviation. 

3.  Secondary  Deviation,  which  depends  upon  the  fact  that  when  two  mus- 
cles act  together,  if  one  is  feeble  and  an  effort  is  made  to  contract  it,  the 
increased  innervation  acts  powerfully  upon  the  healthy  muscle,  causing 
increased  contraction.  ''  Its  existence  and  amount  may  be  best  ascertained  by 
subsequently  covering  the  paralyzed  eye  and  making  the  patient  fix  with  the 
unaffected  eye,  which,  to  do  so,  moves  back  to  its  former  position.  The  hand 
or  a  piece  of  paper  may  be  so  placed  as  to  intercept  the  vision  of  the  one  eye, 
while  leaving  it  exposed  to  observation.  A  piece  of  ground  glass  ])laced  over 
the  eye  answers  the  same  purpose.  The  occurrence  of  secondary  deviation 
depends  on  the  fact  that  normally  two  muscles  which  act  together  are  equally 
innervated  for  a  given  movement.  If  one  is  weak,  and  an  effort  is  made  to 
contract  it  (as  in  fixing  with  that  eye),  the  increased  innervation  influences 
also  the  other  muscle  and  causes  an  undue  contraction.  It  is  as  if  a  rein 
acted  equally  on  a  hard-mouthed  and  a  tender-mouthed  horse  yoked  together ; 
the  effort  to  make  the  former  deviate  would  cause  an  excessive  deviation  of 
the  latter  "  (Gowers). 


AFFECTIOyS    OF    THE   MOTOIl .  yERVES    OF    THE   EYE.     823 

4.  Erroneous  Projection. — "  We  judge  of  tlie  relation  of  external  objects 
to  each  other  by  the  relation  of  their  images  on  the  retina;  we  judge  of  their 
relation  to  our  own  body  by  the  position  of  the  eyeball  as  indicated  to  us  by 
the  innervation  we  give  to  the  ocular  muscles"  (Gowers).  If  an  object  moves, 
we  follow  it  with  the  eyes  and  judge  of  its  position  by  the  amount  of  move- 
ment. When  one  muscle  is  weak,  the  increased  innervation  "  gives  the 
impression  of  a  greater  movement  of  the  eye  than  has  really  taken  place,  and 
suggests  that  the  objects  seen  are  farther  on  that  side  than  they  really  are," 
and  in  attempting  to  touch  it  the  finger  goes  beyond  it.  As  equilibration  in 
great  part  depends  upon  knowledge  of  the  position  and  relation  of  external 
objects  derived  from  action  of  the  eye-muscles,  the  erroneous  projection  result- 
ing from  paralysis  "  destroys  the  harmony  between  the  visual  imi)ressions  and 
the  others  that  are  correct,"  and  leads  in  this  way  to  giddiness  or  ocular 
vertigo. 

5.  Double  Vision,  or  Diplopia. — Owing  to  paralysis  of  the  muscles  the 
visual  axes  do  not  correspond,  and  there  is  a  double  vision  :  that  seen  by  the 
sound  eye  is  called  the  true,  that  by  the  paralyzed  eye  the  false,  image.  When 
the  false  image  is  on  the  same  side  of  the  other  as  the  eye  by  which  it  is  seen, 
it  is  known  as  simple  or  homonymous  diplopia,  in  which,  for  example,  the 
right-hand  image  corresponds  to  the  right  eye,  and  the  left-hand  image  to 
the  left  eye.  In  crossed  diplopia  the  false  image  is  on  the  other  side;  for 
example,  the  right-hand  image  belongs  to  the  left  eye,  and  the  left-hand 
image  to  the  right  eye.  The  diplopia  is  simple  in  convergent  squint,  crossed 
in  divergent  squint. 

Ophthalmoplegia. 

Under  this  term  is  described  a  chronic  progressive  paralysis  of  the  ocular 
muscles  which  may  involve  the  external  or  internal  groujis  alone  or  in  com- 
bination, hence  the  names,  "  ojihthalmoplegia  externa"  and  ''ophthalmoplegia 
interna."  The  condition  is  due  to  a  degenerative  change  in  the  nuclei  of  the 
ocular  nerves,  and  is  described  by  Gowers  as  nuclear  ocular  ]ialsy.  In  the 
external  form  the  levators  of  the  eyelids  are  usually  first  involved,  then  grad- 
ually the  power  is  imj)aired  in  the  other  muscles,  and  finally  the  eyeballs 
become  almost  fixed,  so  that  in  order  to  view  objects  out  of  a  straight  line  the 
patient  has  to  move  his  head  in  a  very  characteristic  manner.  The  eyelids  droop 
and  there  is  usually  slight  protrusion  of  the  eyeballs.  The  affection  is  met  with 
in  association  with  general  paralysis,  locomotor  ataxia,  and  sometimes  in  pro- 
gressive muscular  atrophy.  Hiit(!hinson  regarded  syj)hilis  as  the  most  important 
cause,  but  in  the  recent  monograph  of  Siemerling  it  is  stated  that  of  the  62 
cases  on  record,  in  only  11  could  syphilis  be  definitely  detcnniiicd.  Atrophy 
of  the  optic  nerve  and  afT'cctions  of  the  other  cranial  nerves  are  frequently 
associated  with  if.  ^IcDtMl  disorders  were  present  in  11  of  the  02  cases  ana- 
lyzed bv  Siemerling.  Jiristowe  has  rcportcfl  2  cases  in  which  (he  cNtcriKd  oph- 
thalmo))legia  was  ])robal)ly  functional. 

Ophthalmoplegia  inf<'rna  is  a  term  applied  to  slow  progressive  loss  (»r  power 
of  the  ciliary  muscle  and  the  iris.     The  condition  may  occur  alone,  but  more 


824  DISEASES    OF    THE   NERVES. 

commonly  is  associated  with  tiie  external  form,  and  is  then  spoken  of"  as  total 
ophthalmoplegia.  Possibly  in  some  cases  the  internal  form  may  depend  upon 
disease  of  the  ciliary  ganglion.  Although,  as  a  rule,  the  ophthalmoplegia  is  a 
chronic  process,  there  is  an  acute  form  which  may  lead  to  complete  loss  of 
power  within  ten  or  fourteen  days,  due  to  rapid  softening  of  the  nuclei  of  the 
ocular  nerves.  There  are  cerebral  disturbances  and  sometimes  ataxic  symp- 
toms.   It  was  to  this  condition  that  Wernicke  gave  the  name  polio-encephaliiis 

superior  acuta. 

Spasm  of  the  Ocular  Muscles. 

In  hysteria  there  may  be  an  intermittent  spasm  causing  rapid  lateral  move- 
ment of  the  eyes,  with  or  without  associated  jerkings  in  other  muscles  of  the 
body.  In  hysterical  convulsions  the  eyes  are  usually  drawn  up,  so  that  the 
cornese  are  completely  covered  by  the  lids.  In  disease  at  the  base  of  the 
brain,  particularly  meningitis,  tonic,  more  rarely  clonic,  spasm  may  occur. 
The  form  known  as  conjugate  deviation  of  the  eyes,  which  is  present  in  cere- 
bral lesions,  will  be  subsequently  described. 

The  most  remarkable  form  is  the  clonic  rhythmical  spasm  known  as 
nystagmus,  in  which  the  movements  are  bilateral  and  as  a  rule  horizontal. 
When  one-sided  the  movements  are  most  frequently  vertical.  It  occurs  under 
very  many  conditions,  particularly  in  congenital  and  acquired  brain  lesions 
associated  with  blindness,  in  albinism,  in  miners,  and  in  many  forms  of 
sclerotic  and  chronic  cerebro-spinal  lesions,  such  as  disseminated  sclerosis 
and  Friedreich's  disease.  The  pathology  of  the  condition  is  not  yet  well 
understood. 

Spasm  of  the  levator  palpebrse  is  occasionally  met  with,  and  here  may  be 
mentioned  the  condition  of  hippiis,  or  rhythmical  contraction  and  dilatation  of 
the  iris. 

Treatment  of  Ocular  Palsies. — The  paralysis  due  to  diphtheria  as  a  rule 
disappears  with  time  and  under  a  course  of  tonic  treatment.  When  due  to 
syphilis,  iodide  of  potassium  and  mercury  should  be  given,  and  the  condition 
frequently  improves  rapidly  under  the  use  of  these  drugs.  The  forms  asso- 
ciated with  locomotor  ataxia  are  the  most  obstinate  and  may  resist  all  treat- 
ment. The  group  of  cases  due  to  chronic  degenerative  changes,  as  in  progres- 
sive paresis  or  bulbar  paralysis  and  the  forms  of  ophthalmoplegia,  are  little  if 
at  all  amenable  to  treatment.  When  there  are  acute  symptoms  hot  fomenta- 
tions, counter-irritation,  or  leeches  may  be  used.  The  direct  treatment  of  the 
paralyzed  muscles  by  electricity  is  occasionally  followed  by  good  results,  but  in 
a  large  number  of  cases  no  special  effect  can  be  seen  even  after  prolonged  appli- 
cation. The  diplopia  may  be  relieved  by  the  use  of  a  prism.  It  is  sometimes 
found  necessary  to  cover  the  affected  eye  with  an  opaque  glass.  Various  forms 
of  spasm  of  the  ocular  muscles  are  little  if  at  all  affected  by  treatment. 

Lesions  of  the  Fifth  Nerve. 
W^e  shall  consider  here  paralysis,  spasm,  and  neuralgia. 
(1)  Paralysis. — In  comparison  with  the  facial  and  other  cranial  nerves, 


AFFECTIOXS    OF    THE   FIFTH   XFliVE,  825 

lesions  of  the  trigeminus  causing  paralysis  are  rare.  The  nerve  may  be 
affected  within  tlie  pons  by  luvmorrhage  or  tumors,  rarely  in  chronic  nuclear 
deaeneration,  which  mav  be  widespread  without  aifectino;  the  fifth  nerve.  At 
the  base  of  the  brain  its  position  guards  it,  to  a  certain  extent,  from  compres- 
sion, but  it  is  sometimes  involved  in  fracture,  caries,  or  meningitis.  Tiie 
branches  may  be  affected  as  they  pass  to  their  distribution,  the  ophthalmic 
in  the  cavernous  sinus  by  tumors  or  aneurisms,  the  superior  and  inferior 
maxillary  branches  by  growths  which  invade  the  spheno-maxillary  fossa. 

Symptoms. — (a)  Sensory. — When  the  whole  nerve  is  involved  there  is  loss 
of  sensation  in  the  skin  of  the  corresponding  side  of  the  face  and  head,  the 
conjunctiva,  the  mucous  membrane  of  the  lips,  tongue,  hard  and  soft  palate, 
and  of  the  nose  on  the  same  side.  Tingling  and  numbness  may  precede  the 
ana?sthesia.  The  sense  of  smell  is  usually  affected  in  consequence  of  dryness 
of  the  mucous  membrane.  Trophic  changes  sometimes  occur,  the  salivary, 
lachrymal,  and  buccal  secretions  diminish,  the  gums  may  swell  on  the  affected 
side,  the  teeth  occasionally  become  loose,  and  abrasions  of  the  mucosa  tend  to 
ulcerate.  Herpes  may  develop  about  the  eye  or  about  the  lips,  and  may  be 
accompanied  with  much  pain.  The  cornea  may  become  opaque,  and  finally 
ulcerates.  This  is  not,  however,  a  constant  sequence,  and  is  absent  unless  the 
Gasserian  o-ano-lion  is  affected.  Involvement  of  the  individual  branches  of 
the  sensory  division  causes  loss  of  sensation  in  the  skin  and  mucous  surfaces 
upon  which  they  are  respectively  distributed. 

(6)  Motor. — Inability  to  use  the  muscles  of  mastication  on  the  affected  side 
is  the  characteristic  feature  of  paralysis  of  the  motor  division.  It  can  be 
tested  by  asking  the  patient  to  close  the  jaw  forcibly,  when  the  temporal  and 
masseter  muscles  on  the  affected  side  are  not  felt  to  contract  or  do  so  with 
great  feebleness.  Owing  to  involvement  of  the  pterygoid,  which  cannot  be 
moved  toward  the  affected  side  in  the  act  of  chewing,  the  jaw  when  depressed 
deviates  to  tiie  paralyzed  side.  Paralysis  of  the  motor  branches  of  the  fifth 
nerve  usually  follows  a  lesion  of  the  trunk.  Occasionally  the  paralysis  is  due 
to  cortical  lesion,  usually  bilateral.  Hirthas  reported  an  instance  of  unilateral 
lesion,  a  psammoma  involving  the  lower  third  of  the  ascending  frontal  convo- 
lution and  the  adjacent  portions  of  the  second  and  third  frontal  convolutions, 
associated  with  paralysis  of  the  muscles  of  mastication. 

Guddtory  Symptoias. — The  sense  of  taste  is,  as  a  rule,  lost  in  tlic  anterior 
two-thirds  of  the  tongue  on  the  affected  side.  The  gustatory  fibres  pass  from 
the  chorda  tympani  to  the  lingual  branch  of  the  fifth.  Loss  of  taste  does  not 
invariably  follow  paralysis  of  the  fifth  nerve.  "  Probably  the  exceptions  are 
cases  of  partial  disease  or  disease  within  the  pons,  where  the  taste-path  has  a 
sejxirate  course  "  (Gowers). 

The  diagnosis  of  trifacial  ])aralysis  rarely  offers  any  special  dillicultics,  the 
distribution  of  the  anaesthesia  and  the  loss  of  jxtwcr  in  the  muscles  of  mastica- 
ti(jn  fi»rm  such  characteristic  features.  The  j)rclimiii;n y  pain  and  liypera\sthesia 
may  be  mistaken  for  neuralgia.  The  determination  of  the  site  of  the  lesion 
dejjcnds  on  the  distribution  of  the  anajsthesia  and  associated  paralysis.     When 


826  DISEASES    OF    THE   NERVES. 

the  ophthalmic  division  is  involved  alone,  the  lesion  is  usually  at  the  sphenoidal 
fissure  or  within  the  orbit.  The  lower  divisions  are  not  infrequently  involved 
in  tumors  of  the  superior  maxillary  bone. 

(2)  Spasm  of  the  Muscles  of  Mastication. — Trismus,  or  the  masti- 
catory spasm  of  Romberg,  is  often  an  associated  feature  in  general  convulsive 
attacks,  sometimes  an  independent  affection.  The  contractions  may  be  either 
tonic  or  clonic.  In  the  former  the  muscles  of  mastication  are  in  firm  contrac- 
tion, so  that  the  jaws  are  kept  close  together,  the  condition  know'n  as  lockjaw, 
a  symptom  which  occurs  early  in  tetanus  and  is  met  with  in  some  cases  of 
tetany.  Occasionally  it  is  an  hysterical  manifestation.  Less  frequent  causes 
are  reflex  irritation  from  the  teeth  and  organic  disease  near  the  motor  nucleus 
of  the  fifth  nerve.  Clonic  spasm  occurs  either  in  a  series  of  quick  contractions, 
as  in  chattering  of  the  teeth,  or  as  forcible  single  contractions,  which  are  some- 
times seen  in  chorea  and  in  iiysteria. 

Treatment. — For  the  organic  lesions  involving  the  fiftii  nerve  little  can  be 
done  beyond  relieving  the  pain,  which  may  require  morphine.  The  prelim- 
inary irritation  and  hypersesthesia  are  relieved  by  warm  applications.  If  there 
be  a  history  of  syphilis,  mercury  and  iodide  of  potassium  may  be  given.  Fric- 
tions and  faradization  of  the  affected  side  of  the  face  are  recommended. 

(3)  Neuralgia. — Neuralgia  of  the  fifth  nerve  (prosopalgia ;  tic  doulou- 
reux) is  the  most  common  and  distressing  of  all  painful  affections  of  the  nerve.«. 
All  of  the  branches  are  rarely  involved  ;  most  commonly  the  ophthaluiic  alone 
or  the  two  upper  divisions. 

Wlien  the  ophthalmic  division  is  involved,  the  pain  is  referred  to  the  dis- 
tribution of  the  supraorbital  branch,  as  a  rule  on  one  side  only.  There  are 
tender  points  at  the  supraorbital  notch,  at  the  inner  angle  of  the  or))it,  and 
sometimes  on  the  nose  at  the  junction  of  the  cartilage  with  the  bone.  The 
pain  is  usually  paroxysmal  and  may  be  of  extreme  severity.  It  is  usually 
accom})anied  with  intolerance  of  light,  sometimes  wath  spasm  of  the  orbital 
muscles,  lachryraation,  and  redness  of  the  conjinictiva.  The  whole  eyeball 
may  ache  or  there  may  be  an  intense  pain  at  the  back  of  the  eye.  The  pain 
extends  over  the  brow  and  forehead,  and  the  skin  may  be  so  tender  that  the 
patient  may  be  unable  to  wear  his  hat.  Owing  to  the  paroxysmal  character 
and  the  supposed  association  with  malaria,  neuralgia  of  this  branch  was  for- 
merly spoken  of  as  "  brow  ague."  The  affection  must  not  be  mistaken  for 
migraine,  the  painful  symptoms  of  which  are,  however,  due  to  involvement  of 
this  branch  of  the  fifth  nerve.  It  is  to  be  remembered,  too,  in  bilateral  cases 
that  errors  of  refraction  may  lie  at  the  root  of  the  whole  mischief.  Herpes 
may  occasionally  develop  during  an  attack.  Spasmodic  contractions  of  the 
face-muscles  on  the  affected  side  are  occasionally  present. 

The  superior  maxillary  is  less  frequently  involved.  There  is  a  tender  point 
at  the  infraorbital  canal,  and  the  pain  is  rather  more  concentrated  and  limited 
than  in  the  neuralgia  of  the  upper  division,  being  chiefly  along  the  upper  teeth 
and  gums.  Salivation  may  occur  with  it.  In  inferior  maxillary  neuralgia 
there  are  painful  spots  along  the  auriculo-temporal  nerve,  and  the  pain  radiates 


AFFECTIONS    OF    THE   FACIAL    NERVE.  827 

about  the  ear  and  along  the  course  of  t.he  inferior  dental  nerve.  Tender  points 
occur  about  the  side  of  the  head,  particularly  at  the  parietal  eminence. 

Trifacial  neuralgia  is  most  commonly  met  with  in  enfeebled  subjects,  par- 
ticularly in  women  and  in  association  with  aujijmia  and  chlorosis.  There  are 
instances  in  which  it  seems  dependent  upon  malaria,  but  the  malarial  charac- 
ter in  many  of  the  cases  has  been  attributed  to  the  periodicity  of  the  attacks. 
The  cases  vary  extremely  in  their  character  and  duration.  There  are  instances 
in  which  the  trophic  and  vaso-motor  disturbances  arc  particularly  marked; 
thus  the  skin  may  become  glossy  and  indurated  and  the  subcutaneous  fat  may 
increase.  Pigmentary  changes  sometimes  occur  on  the  skin,  and  the  hair  or 
the  beard  on  the  affected  side  may  become  gray. 

The  cases  associated  with  spasmodic  tic  are  sometimes  of  the  most  aggra- 
vated character,  and  tiie  attacks  occur  with  frightful  intensity  and  render  the 
patient's  life  unendurable. 

Treatment. — Careful  investigation  should  be  made  into  possible  sources  of 
reflex  irritation.  Tonic  and  hygienic  measures  of  all  sorts  should  be  utilized, 
as  in  very  many  cases  neuralgia  is,  as  has  been  expressed,  the  cry  of  a  badly- 
nourished  nervous  system.  A  change  of  air  will  sometimes  relieve  a  severe 
neuralgia,  and  even  obstinate  cases  may  yield  to  a  prolonged  residence  in  the 
mountains  with  an  out-of-door  life  and  plenty  of  exercise.  Iron  is  often  a 
specific  in  the  cases  associated  with  chlorosis  and  anaemia.  Arsenic  is  also 
very  beneficial  in  these  forms,  and  should  be  given  in  full  doses.  Quinine, 
which  is  so  much  used,  has  probably  no  greater  value  in  neuralgia  than  any 
other  bitter  tonic,  except  in  the  rare  instances  in  which  neuralgia  is  definitely 
associated  with  malarial  poisoning.  Strychnine,  cod-liver  oil,  and  ])hosphorus 
are  sometimes  useful.  For  the  relief  of  the  j)ain  antifebrin  and  antipyrine 
may  be  tried,  though  their  value  has  been  much  exaggerated.  Morphine 
should  be  given  with  great  caution,  and  only  after  other  remedies  have  been 
tried  in  vain.  Small  doses  given  hyj)odermically  are  usually  very  efficacious, 
but  on  no  consideration  should  a  patient  be  allowed  to  use  the  hypodermic 
syringe.  Gelsemiura  may  be  tried,  and  in  frequent  doses  of  the  tincture  is 
sometimes  of  value.  Valerian,  ammonia,  ether,  and  above  all  alcohol,  some- 
times allay  the  pain.  The  last-named  remedy  should  be  used  with  the  greatest 
caution,  particularly  in  women.  The  pleasant,  soothing  clfcct  of  it  in  many 
cases  of  neuralgia  has  been  the  starting-point  of  habits  which  have  finally 
enslaved  the  patient.  Nitro-glycerin  in  full  doses  is  a  remedy  which  is  some- 
times efficacious,  particularly  in  the  chronic  cases.  Of  local  applications, 
liniments  of  belladonna,  chloroform,  and  menthol,  the  ointments  of  acouitine 
and  veratrine,  and  counter-irritation  with  the  thcrmo-cautery  or  small  blisters 
over  the  painful  points,  may  be  tried.  P]lcctricity  is  often  of  nnich  service, 
particularly   the  continuous  current,   and    wIkmi   frc(|M(Mitly   repented    is   very 

soothing. 

Lesions  of  the  Facial  Nerve. 

Paiialysis  (Bell's  Palsy)  may  be  due  to — (1)  iiivolvcnicnl  of  the 
nerve-fibres  from  the  cortex  cerebri   to  I  he  nucleus  in  the    medulla;  (2)  to 


828  DISEASES    OF   THE   NERVES. 

lesions  of  the  nucleus  iti^elf;  and  (3)  to  peripheral  lesions  involving  the 
nerve-trunk  in  its  tortuous  course  witliin  the  pons  and  through  the  wall  of 
the  skull  or  in   its  course  after  leaving  the  styloid  foramen. 

(1)  Facial  Paralysis  of  Cerebral  Origin. — This,  also  known  as 
the  supranuclear  form,  may  be  due  to  a  lesion  of  the  cortical  centre  presiding 
over  the  lower  facial  muscles  which  is  situated  in  the  lower  part  of  the  ascend- 
ing frontal  convolution.  Cases  of  limited  lesion  involving  the  facial  centre 
alone  and  causing  facial  hemiplegia  are  rare  ;  more  commonly  on  the  left  side 
the  speech-centres  are  also  involved  and  the  centres  for  the  hand  and  arm. 
Softening  from  arterio-sclerosis,  tumors,  and  localized  meningitis,  tuberculous 
or  syphilitic,  are  the  common  causes  of  cortical  facial  palsy.  The  fibres  may 
be  involved  between  the  cortical  centres  and  the  nucleus  in  the  medulla,  and 
with  them,  as  a  rule,  the  motor  fibres  of  the  arm  and  leg,  so  that  the  facial 
palsy  is  part  of  a  hemiplegia. 

The  supranuclear  facial  paralysis  is  distinguished  from  the  peripheral  form 
by  several  well-marked  features.  The  orbicularis  palpebrarum  and  frontalis 
muscles  are  not  involved,  so  that,  for  instance,  in  hemiplegia  the  patient  can 
close  the  eye  and  frown  on  the  paralyzed  side.  While  voluntary  movements 
are  lost  in  the  paralyzed  muscles,  during  emotion,  as  in  smiling,  the  paralyzed 
muscles  may  be  moved,  which  is  never  the  case  in  the  periplieral  form. 
Another  difference  of  great  importance  is  the  persistence  of  the  normal 
electrical  excitability  of  both  nerves  and  muscles.  In  rare  instances  of 
hemiplegia  the  orbicularis  palpebrarum  is  involved  in  association,  it  is  said, 
with  lesion  of  the  lenticular  nucleus.  Broadbent  explains  the  immunity  of 
the  upper  facial  muscles  in  hemiplegia  by  the  fact  that  the  bilateral  move- 
ments of  the  body,  such  as  those  of  the  eyes  and  trunk  and  the  larynx,  are 
represented  in  both  hemispheres ;  that  is  to  say,  either  hemisphere  can  excite 
bilateral  movements. 

(2)  Nuclear  Facial  Paralysis. — The  facial  nucleus  forms  a  group  of 
large  ganglion-cells,  occupying  that  portion  of  the  gray  substance  of  the  fas- 
ciculus teres  which  lies  immediately  behind  the  nucleus  of  the  sixth  nerve  in 
the  floor  of  the  fourth  ventricle. 

The  nuclei  are  rarely  attacked  alone,  but  may  be  in  tumors,  haemorrhage, 
and  softening;  more  rarely  in  acute  poliomyelitis.  In  lesions  in  the  neighbor- 
hood of  the  pons  the  facial  nucleus  on  one  side,  that  of  the  sixth  nerve  too, 
and  the  motor  path  may  be  involved,  producing  facial  paralysis  on  the  same 
side  as  the  lesion  and  paralysis  of  the  arm  and  leg  on  the  opposite  side — a 
condition  known  as  crossed  paralysis.  (See  Fig.  57.)  The  symptoms  of  facial 
paralysis  of  nuclear  origin  are  identical  with  those  of  involvement  of  the  nerve 
itself.  The  superior  facial  muscles  are  involved  and  the  electrical  changes  are 
present. 

(3)  Paralysis  from  Involvement  of  the  Nerve-trunk. — The 
nerve  may  be  involved  as  it  passes  through  the  pons  from  the  nucleus,  at  the 
base  of  the  skull,  in  its  prolonged  course  tbrough  the  temporal  bone,  or  at  its 
point  of  emergence.     In  the  pons  the   fibres  may   be    affected  between    the 


AFFECTIONS    OF    THE   FACIAL    NERVE. 


829 


nuclei  in  the  floor  of  the  fourth  ventriele  and  the  point  of  emergence  of  the 
nerve,  in  which  case  there  may  be  an  akernating  or  crossed  paralysis,  in  which 
the  face  on  the  same  side  and  the  arm  and  leg  on  the  opposite  side  are  paralyzed. 
This  only  occurs  when  the  lesion  is  in  the  lower  region  of  the  pons. 

At  the  base  of  the  brain  the  nerve  is  liable  to  be  compressed  by  meningeal 
exudation  or  tumors,  and  is  occasionally  torn  in  fractures.  Within  tiie  tem- 
poral bone  the  nerve  is  frequently  attacked  in  c)titis  media.     At  the  styloid 


Crossed  Pyramidal  Fibres 

-•>''■}!  _coRo 

Oima  PYRAMIML  FIBRES 

Motor  Tract  (after  Starr):  .%  fissure  of  Sylvius  ;  NL,  lenticular  nucleus;  07",  optic  thalamus;  0,  olivary 
body.  The  tracts  for  the  face,  arm,  and  les  gather  in  the  capsule,  and  i>ass  lo-iether  to  the  lower  pons 
where  the  face-fibres  cross  to  the  opposite  seventh  nerve  nucleus,  while  the  others  i>ass  on  to  tlie  lower 
medulla,  where  they  partially  decussate  to  enter  the  lateral  columns  of  the  cord  :  the  ndu-decussatiiiK 
fibres  pass  to  the  anterior  median  columns.  The  ellect  of  a  lesion  situated  at  three  points  in  the  tract 
is  sliown  on  the  left  side  of  the  fiKtire  at  A',  }'.  Z.  At  ^^  the  lesion  would  involve  the  left  facial  nerve 
and  tlie  left  pyramidal  tract  above  the  decussation,  producing  fiicial  paralysis  on  the  left  side  and 
paralysis  of  the  arm  and  leg  on  the  opposite  side— crossed  paralysis. 

foramen  the  nerve  may  be  involved  in  blows,  injuries,  as  by  the  pressure  of 
forceps  in  an  instrumental  delivery,  and  the  nerve  may  be  cut  in  the  removal 
of  tumors  in  the  parotid  region.  The  mo.st  common  cause  is  ex])osure  to  cold, 
l)articularly  to  a  draught  when  riding  in  a  carriage  with  the  window  down. 
This  is  usually  attributed  to  a  neuritis  of  the  nerve  in  (he  Fall(»|)iaii  a(|iicdMct. 
Symptoms. — The  onset  is,  as  a  rule,  abriii)t,  and  is  not  oltcn  preceded  by 
pain  or  discomfoit.  In  the  cases  following  exposure  to  cold  it  is  a  commiMi 
hi.'^tory  to  find  that  the  patient  wal<es  in  the  inorniiig  to  liiid  llic  l;i<-c  paraly/cd. 
In  the  peripheral  form  ail  tlic  hr;iii<'|ics  :irc  involved,  and  llie  lii.c  on  the 
affected  side  is   immobile  and    can    ncillier   be   ni(.ve<l   at  will   nor  does  it  Join 


830  DISEASES    OF    THE   NERVES. 

in  any  emotional  movements,  Wlien  at  rest  it  is  seen  that  the  skin  on  the 
affected  side  is  smooth  and  the  wrinkles  are  effaced.  This,  of  course,  is  not 
so  noticeable  in  young  persons.  The  angle  of  the  mouth  is  somewhat  lowered 
and  the  naso-labial  fold  is  not  so  marked.  The  lower  lid  may  droop  a  little 
and  the  eye  waters.  The  eye  on  the  affected  side  cannot  bcclosed  voluntarily. 
In  smiling  or  laughing  the  angle  of  the  mouth  is  drawn  to  the  healthy  side, 
while  on  the  paralyzed  side  the  lips  remain  in  contact.  The  forehead  cannot 
be  wrinkled,  nor  can  the  patient  show  his  upper  teeth  on  the  affected  side,  nor 
can  he  whistle.  In  sniffing  there  is  no  movement  of  the  nostril  on  the  para- 
lyzed side.  In  speaking  the  pronunciation  of  labial  sounds  may  be  slightly 
impaired.  Owing  to  the  paralysis  of  the  buccinator,  food  collects  between  the 
cheek  and  the  jaw  on  the  affected  side ;  the  tongue  when  protruded  looks  as  if 
it  were  pushed  to  the  paralyzed  side,  but  if  its  position  is  estimated  from  the 
incisor  teeth,  it  will  be  found  to  be  in  the  middle  line.  It  is  usually  stated 
that  the  soft  palate  and  uvula  are  paralyzed  on  the  same  side,  but  this  is 
denied  by  both  Gowers  and  Hughlings  Jackson,  and,  according  to  Horsley 
and  Beevor,  the  levator  palati  is  innervated  by  the  accessory  nerve.  When 
the  paralysis  is  due  to  an  intratemporal  lesion,  there  is,  in  addition  to  the 
above  symptoms,  loss  of  the  sense  of  taste  in  the  anterior  part  of  the  tongue 
on  the  affected  side,  owing  to  paralysis  of  the  chorda  tympani  nerve. 

Disturbance  of  hearing  may  exist  with  facial  paralysis,  and  is  usually  due 
to  extensive  otitis  media.  There  mav  be  increased  sensitiveness  to  sounds, 
owing  to  paralysis  of  the  stapedius,  which  diminishes  the  amplitude  of  the 
vibration  of  the  tympanic  membrane.     Tinnitus  may  be  present. 

Among  other  symptoms  occasionally  '3resent  in  facial  paralysis  may  be 
mentioned  herpes  and  neuralgic  pains.  The  electrical  reactions  in  Bell's 
palsy  are  those  of  a  peripheral  paralysis.  The  nerve  rapidly  loses  both 
faradic  and  galvanic  excitability,  which  may  completely  disappear  within 
ten  days. 

Erb  gives  the  following  rules  :  The  prognosis  is  good,  and  recovery  occurs 
in  from  fifteen  to  twenty  days  if  there  is  no  change,  either  faradic  or  galvanic. 
If  the  faradic  and  galvanic  excitability  of  the  nerve  is  only  lessened  and  that 
of  the  muscle  increased  to  the  galvanic  current,  and  the  contraction  formula 
altered  (the  contraction  sluggish,  ACC>CCC)  the  outlook  is  favorable,  and 
recovery  will  jjrobably  take  place  in  from  four  to  six  weeks  or  may  be  delayed 
for  from  eight  to  ten  weeks.  If  the  faradic  and  galvanic  excitability  of  the 
nerves  and  the  faradic  excitability  of  the  nuiscles  are  lost,  and  the  galvanic 
excitability  of  the  muscle  quantitatively  increased  and  qualitatively  changed 
(reaction  of  degeneration),  and  if  the  mechanical  excitability  is  altered,  the 
prognosis  is  relatively  unfavorable,  and  recovery  may  not  take  place  for  from 
two  to  eight  months,  or  may  even  be  delayed  for  as  long  as  twelve  or  fifteen 
months. 

The  duration  of  the  paralysis  is  variable.  Recovery  usually  follows  the 
paralysis  from  cold,  though  it  may  be  delayed  for  months.  In  the  traumatic 
cases  recovery  is  possible,  but  the  loss  of  power  in  these  may  be  permanent. 


AFFECTIOXS    OF    THE   FACIAL    XFRVF.  831 

When  due  to  syphilis  recovery  is  common.  In  tlie  cases  clue  to  middle-ear 
disease  the  outlook  is  less  favorable. 

In  any  case  the  electrical  reactic>n  gives  the  most  valuable  indications  upon 
which  the  prognosis  can  be  based.  When  the  paralysis  is  permanent,  the 
muscles  are  toneless  and  there  are  no  contractures.  Spontaneous  twitchings 
may  be  noticed  at  times  in  the  muscles.  In  these  late  cases  without  any 
improvement  there  may  be  contractures  in  the  muscles,  drawing  the  mouth 
toward  the  paralyzed  side,  and  the  wrinkles  may  again  appear,  and  in  looking 
at  the  face  the  first  impression  may  be  that  the  affected  side  is  the  sound  one, 
but  this  is  soon  corrected  by  asking  the  patient  to  smile,  when  it  is  seen  which 
side  of  the  face  has  the  active  movement. 

Diagnosis. — The  existence  of  facial  paralysis  is  usually  determined  at  a 
glance.  The  diagnosis  of  the  site  is  sometimes  difficult.  The  following 
resume  may  be  given  : 

(1)  Paralysis  due  to  a  lesion  of  the  nerve  outside  the  stylo-mastoid 
foramen  involves  both  the  upper  and  lower  divisions.  All  reflex  movements 
are  lost  and  the  reaction  of  degeneration  is  present. 

(2)  When  due  to  lesion  within  the  Fallopian  canal  the  features  are  the  same 
as  those  just  mentioned,  and  there  are,  in  addition,  alterations  in  the  sense  of 
taste  and  increased  sensitiveness  in  hearing. 

(3)  A  nuclear  lesion  produces  a  paralysis  similar  in  distribution  to  the 
peripheral  form.  There  may  be  crossed  paralysis,  involvement  of  the  facial 
on  one  side  and  of  the  arm  and  leg  on  the  other,  and  the  sixth  nerve  on  the 
same  side  is  usually  involved,  causing  internal  strabismus. 

(4)  The  facial  })alsy  of  cerebral  origin  (supranuclear)  involves,  as  a  rule, 
only  the  lower  facial  muscles,  so  that  the  patient  can  elevate  the  eyebrows  and 
close  the  eye.  The  reflexes  are  preserved,  and  there  is  not  the  reaction  of 
defeneration.  If  due  to  involvement  of  the  fibres  in  the  cortico-bulbar  motor 
path,  there  is  usually  hemiplegia  and  the  paralysis  of  the  face  and  of  the 
limbs  is  on  the  same  side.  The  paralysis  due  to  a  cortical  lesion  may  be  a 
monoplegia  confined  to  the  facial  muscles.  On  the  left  side  it  may  be  accom- 
panied with  aphasia,  and  in  some  instances  the  arm-centres  are  also  involved. 

Treatment. — In  the  so-called  rheumatic  cases  hot  aj)])lications  may  be 
made,  but  the  disease  rarely  seems  to  be  progressive,  and  the  damage  is  done 
before  any  palliative  treatment  can  be  adoj)ted.  The  thermo-cautery  may  be 
lightly  api^lied  at  intervals  over  the  mastoid  region  and  over  the  course  of  the 
nerve.  This  is  much  more  satisOictory  and  very  much  less  painful  than  blis- 
tering. Iodide  of  potassiinn  should  be  given  internally,  and  in  increasing 
doses,  if  svphilis  be  suspected.  Sui)se<|uently  (he  galvanic  current  should  be 
systeiiiaticallv  employed,  and  persevered  with  so  long  as  there  is  any  reaction, 
as  when  this  is  present  there  is  always  a  prospect  of  recovery.  The  positive 
pole  may  be  placed  behind  tlic  car  and  tlic  negative  pole  passed  over  the 
zvgomatic  and  other  nmscles.  The  :i|)plication  siioiild  be  made  daily  for  from 
ten  to  fifteen  minutes.  With  the  electricity  may  be  cond>ined  mas.sage  of  the 
mu-scles  of  the  face. 


832  DISEASES    OF    THE   NERVES. 

Spasm  of  Facial  Muscles  (Mimic  Spasm  ;  Convulsive  Tic). — The 
contraction,  which  is  usually  clonic,  may  be  limited  to  certain  groups  of  mus- 
cles or  involve  all  those  of  one  side ;  occasionally  it  is  bilateral.  Various 
groups  of  cases  may  be  recognized  : 

(«)  The  secondary  form  following  paralysis,  and  consisting  in  spontaneous 
clonic  twitch ings  recurring  at  irregular  intervals  in  the  paral^'zed  muscles. 

(6)  Cases  due  to  the  irritation  of  an  organic  brain  lesion,  either  of  the  cor- 
tex, as  in  a  case  of  Berkley's  in  whi(;h  a  lesion  of  the  ascending  frontal  con- 
volution caused  persistent  clonic  spasm  limited  to  the  zygomatic  muscle,  or 
pressure  on  the  facial  nerve  by  a  new  growth  or  an  aneurism  at  the  base  of  the 
brain. 

(c)  In  many  cases,  particularly  in  adults,  no  cause  can  be  assigned.  This, 
which  Gowers  calls  the  idiopathic  form,  is  most  frequent  in  females,  and  fol- 
lows in  some  ilistances  mental  anxiety  and  shock. 

{d)  Cases  which  appear  to  have  a  reflex  origin,  and  which  are  associated  with 
irritation  in  branches  of  the  fifth  nerve,  as  in  eye-strain,  diseased  teeth,  and 
naso-pharyngeal  disorders.  Some  have  attributed  the  affection  in  children  to 
the  irritation  of  worms.  Cases  due  to  these  causes  are  much  more  common  in 
children,  in  whom  the  spasm,  known  also  as  habit  spasm  and  by  some  as  hab- 
it chorea,  may  be  limited  to  the  facial  muscles,  but  may  be  met  with  in  other 
groups." 

Lastly,  facial  spasm  may  form  a  })art  of  the  affection  described  by  the 
the  French  as  tic  convulsif  or  as  Gilles  de  la  Tourette's  disease,  which  is 
characterized  by  involuntary  spasmodic  jerkings  in  certain  muscle-groups, 
particularly  those  of  the  face,  explosive  utterances,  often  bad  language — 
coprolalia — and  fixed  ideas,  such  as  arithmomania. 

Symptoms. — The  contractions  are  usually  of  a  rapid,  electric-like  charac- 
ter, sometimes  a  series  of  quick,  quivering  contractions.  The  orbiculares 
oculorum  are  most  frequently  involved,  causing  a  form  known  as  the  nicti- 
tating and  blepharospasm,  in  which  the  eye  is  closed  with  lightning-like 
rapidity.  In  some  cases,  when  both  sides  are  affected,  the  patient  can  scarcely 
see,  owing  to  the  constantly-recurring  contraction.  More  frequently  the  lateral 
facial  muscles  are  also  involved,  and  there  is  constant  twitching  of  the  side  of 
the  face,  with  partial  closure  of  the  eye.  The  frontalis  muscle  is  not  often 
involved.  In  severe  cases  the  depressors  of  the  angle  of  the  mouth,  the  levator 
menti,  and  the  plastysma  myoides  are  affected.  Occasionally  the  muscles  of 
the  tongue,  which  is  protruded  quickly  as  the  patient  talks,  and  occasionally 
the  muscles  of  the  palate  and  uvula,  are  involved.  The  contractions  are  aggra- 
vated by  emotion  and  reduced  by  rest  and  quiet.  There  is  no  loss  of  power 
in  the  muscles  and  no  pain.  Tender  points  are  sometimes  found  in  the  course 
of  the  fifth  nerve,  particularly  in  the  supraorbital  branch.  The  spasm  occa- 
sionally extends  from  the  face  to  the  muscles  of  the  neck  and  arms. 

The  outlook  is  favorable  in  the  cases  in  which  a  source  of  definite  irritation 
can  be  traced.  The  idiopathic  cases  coming  on  in  the  middle  life  in  women 
are  as  a  rule  incurable. 


AFFECTIONS    OF    THE   AUDFrORY  NERVES.  833 

Treatment. — In  cliiklrcn  the  sources  of  reflex  irritation  should  be  carefully 
sought  for.  Eye-strain  should  he  excluded,  the  naso-pharynx  explored,  and 
decayed  teeth  removed  or  fdicd.  When  tender  spots  exist  along  the  fifth 
nerve,  small  blisters  may  be  applied  or  the  thermo-cautery.  Electricity, 
which  is  given  in  nearly  all  cases  a  thorough  trial,  rarely  proves  successful. 
Hypodermics  of  strychnine  are  recommended.  Freezing  the  face  with  the  ether 
spray  is  in  some  instances  beneficial.  Stretching  or  section  of  the  facial  nerve 
has  been  employed  in  many  cases,  and  the  spasm  has  often  disappearal  temjK)- 
rarily.     Strychnine,  arsenic,  and  iron  may  be  used. 

Lesions  of  the  Auditory  Nerves. 

The  central  relations  of  the  auditory  nerves  are  with  the  first  temporal 
gyri.  Experimentally,  bilateral  destruction  of  these  gyri  in  monkeys  causes 
deafness.  Cases  of  disea.se  in  man  indicate  that  the  situation  is  the  same. 
On  the  left  side  destruction  of  the  first  temporal  gyrus  causes  the  condition 
known  as  word-deafne.ss,  an  inability  to  understand  the  meaning  of  words, 
thouo;h  thev  may  still  be  recognized  as  sounds. 

Disturbance  of  function  is  not  common  as  a  result  of  lesion  of  the  centre  or 
of  the  auditory  path  ;  much  more  commonly  deafness  results  from  disease  of 
the  nerve  after  it  has  left  the  nucleus  in  the  floor  of  the  fourth  ventricle,  or 
much  more  frequently  from  involvement  of  its  branches  of  distribution  in  the 
vastibule  and  cochlea. 

Desreneration  of  the  anditorv  mujlei  is  rare  even  in  extensive  and  wide- 
spread  bulbar  disease.  The  nerve  may  be  compressed  at  the  base  of  the  brain 
by  tumors  or  the  exudation  of  meniiigitis,  or  may  be  torn  in  fracture.  In 
epidemic  cerebro-spinal  meningitis  the  auditory  nerves  are  not  infrequently 
involved  :  permanent  deafness  may  result,  which  in  the  case  of  very  yoinig 
children  leads  to  deaf-mutism.  A  primary  degeneration  of  the  nerves  has 
been  met  with  in  locomotor  ataxia,  but  it  is  extremely  rare  in  comparison  with 
the  atrophy  of  the  optic  nerve  in  this  disease. 

In  a  large  ])roportion  of  all  cases  with  auditory-nerve  symptoms  the  l(>sion 
is  in  the  distribution  ;  that  is,  in  the  labyrinthine  branches.  Three  groups  of 
.symptoms  may  be  produced  :  hyperaesthesia  and  irritation,  diminished  func- 
tion or   nervous  deafne.s.s,  and  vertigo. 

True  hyperesthesia — hyperacusis — a  condition  in  which  sounds,  even  those 
inaudible  to  other  persons,  are  heard  with  intensity,  is  met  with  occasionally  in 
hysteria,  more  rarely  in  cerebral  disease.  The  term  dvsresthesia  or  dvsacusis 
is  ap|>lied  to  the  .state  in  whieh  ordinary  noises  are  badly  borne,  as  in  headache. 

Tinnitus  au'rium  is  a  term  used  to  cliarMeteri/e  the  subjective  sensation  of 
noises  in  the  ears,  .such  as  roaring,  ringing,  buzzing,  singitig,  ticking,  v\i\ 
Tinnitus  may  accompany  very  many  \nrm<  of  ear  din'Msc".  such  as  w.ix 
i>ressin'r  f)n  the  drum,  otitis  media,  aii<l  atrections  ol'  the  labyrinth.  \ 
very  sudden  and  intense  stiniidalion  of  the  nerve,  such  as  is  caused  by 
the  loud  whistle  of  a  railway  engine,  has  be.'U  known  to  cause  pciiuaneni 
tinnitus.  A  not  uncommon  form  is  that  in  which  a  pidsating  bruit  or  bnzz- 
VoL.  I.— 5.S 


834  DLSEASES    OF   THE   NERVES. 

ing  murmur  is  heard  in  the  car,  ^vllicll  may  be  cau.sed  either  by  abnormal 
contlitions  of  the  circulation,  or  more  commonly  by  some  special  increase  '\ 
in  tlie  sensitiveness  of  tlie  nerve,  so  that  it  is  excited  by  the  blood-current, 
which  under  normal  conditions  flows  noiselessly.  The  murmur  may  be 
present  as  a  very  definite  systolic  bruit  perceptible  to  the  patient  when  he 
rests  his  head  upon  the  })illow,  or  is  even  constantly  present.  In  physicians 
I  have  known  it  to  cause  great  uneasiness,  owing  to  the  supposition  that  an 
aneurism  was  present.  It  is  usually  associated  witli  overwork,  anamia, 
neurasthenia,  or  gout.  The  epileptic  aura  may  consist  of  subjective  auditory 
sensations,  whicli  are  also  sometimes  present  in  migraine.  Occasionally  a 
ticking  or  pulsating  sound  may  be  heard  at  a  distance.  Tiie  former  is  prob- 
ably due  to  the  action  of  muscles  connected  with  the  Eustachian  tube  or  of 
the  levator  palati.  The  condition  may  persist  unchanged  for  years  and  then 
suddenly  disappear. 

The  diag-nosis  of  tinnitus  rarely  offers  any  difficulty,  but  it  may  be  impos- 
sible to  say  upon  what  it  depends.  A  constitutional  disturbance,  such  as  gout, 
may  be  the  cause,  and  I  know  of  a  case  in  which  persistent  and  distressing 
nocturnal  tinnitus  ceased  with  the  abstinence  from  stimulants.  The  ])ulsating 
forms,  in  which  the  sound  resembles  a  bruit,  are  almost  invariably  subjective, 
and  nothing  is  audible  on  auscultation  over  the  ears.  It  is  not  to  be  forgotten 
that  in  young  children  there  is  a  systolic  brain-murmur  sometimes  audible  at  a 
distance.     It  is  occasionally  also  heard  in  adults. 

Impaired  hearing  due  to  involvement  of  the  nerve  is  known  as  nervous 
deafness,  in  contradistinction  to  the  loss  of  hearing  due  to  disease  of  the  tympa- 
num. To  test  for  this  the  tuning-fork  should  be  placed  against  tlie  temporal 
bone.  If  the  vibrations  are  audible,  the  conclusion  may  be  drawn  that  the 
nervous  apparatus  of  hearing  is  not  involved.  On  closure  of  the  meatus  the 
sound  may  also  be  intensified.  The  watch  may  be  used  in  the  same  way,  and 
if  the  sound  is  better  heard  in  contact  with  the  mastoid  pnwess  with  the 
meatus  closed  than  it  is  when  held  opposite  to  the  open  ear,  the  deafness  is 
probably  not  of  nervous  origin.  Among  possible  causes  of  nervous  deafness 
Oowers  mentions  the  following:  "(1)  Symmetrical  disease  of  the  labyrinth, 
which  is  common  ;  acute  inflammation  is  sometimes,  and  chronic  degeneration 
is  often,  bilateral;  double  otitis  has  sometimes  been  mistaken  for  meningitis; 

(2)  symmetrical  lesions  of  the  tv/o  auditory  nerves,  which    are    very    rare; 

(3)  possible  diseases  of  the  medulla;  (4)  a  tumor  in  the  corpora  quadrigemina, 
damaging  the  crustse  of  the  crura  cerebri  ;  (5)  symmetrical  disease  of  each 
temporo-sphenoidal  lobe ;  syphilitic  gummata  caused  this  effect  in  a  case 
recorded  by  ^V^ernicke  and  Friedliinder," 

Vertigo,  or  giddiness,  is  a  very  special  feature  in  certain  forms  of  laby- 
rinthine disease.  It  will  be  considered  separately  under  the  subjects  of 
Vertigo  and  Meniere's  Disease. 

Lesions  op  the  Glosso-pharyngeal  Nerve. 
This  nerve  distributes  motor  fibres  to  the  stylo- pharyngeus  and  the  middle 


AFFECTIONS    OF    THE   IWEUMOGASTRIC  NERVE.  835 

constrictor  of  the  pharynx  ;  sensory  fibres  io  the  ui)per  part  of  tlie  pharynx, 
the  soft  pahite,  and  the  back  of  the  tongue  ;  and  is  the  nerve  of  the  special 
sense  of  taste  for  the  posterior  part  of  tiie  tongue  and  soft  pahite. 

Isohited  paralysis  of  this  nerve  is  extremely  rare.  The  i)haryni»;eal  svnip- 
toius  of  bulbar  paralysis  are  associated  with  involvement  of  the  nuclei  of  this 
nerve,  in  which  case  the  adjacent  ganoHa  are  also  aflected.  In  tumors  at  the 
base  in  meningitis  and  in  diphtheritic  neuritis  the  nerves  mav  be  attacked, 
causing  difficulty  in  swallowing,  loss  of  sensation  in  the  pharynx,  and  loss  of 
the  sense  of  taste  in  the  ])osterior  part  of  the  tongue.  It  seems  not  improbable 
that  the  taste-fibres  of  the  glosso-pharyngoal  come  from  the  fifth  nerve,  since 
'•  there  is  no  instance  on  record  of  loss  of  taste  at  the  back  of  the  tonsi;ue  from 
disease  of  the  roots  of  the  glosso-pharyngeal  nerve,  while  there  is  evidence  that 
disease  of  the  root  of  the  fifth  nerve  causes  loss  of  taste  on  tlie  back  as  well 
as  the  front  of  the  tongue,  and  also  on  the  soft  j)alate  and  palatine  arch " 
(Gowers). 

Here  may  be  mentioned  ap])ropriately  the  distui'bances  of  the  sense  of 
taste.  Loss  of  the  sense  of  taste — ageusia — is  a  connnon  effect  of  morbid 
conditions  of  the  mucous  membrane  of  the  tongue  and  palate:  thus  in  the 
dry  tongue  of  fever  and  the  furred  tongue  of  dyspepsia  taste  is  grcatlv  im- 
paired or  may  be  completely  lost.  The  application  of  very  strong  irritants, 
>uch  as  p('j)per,  vinegar,  and  hot  sauces,  may  dull  the  sense  of  taste.  Affec- 
tions of  the  nerve  mav  be  followed  by  a  loss  of  the  sense.  From  the  tin  and 
sides  of  the  tongue  the  impressions  are  conveyed  through  the  gustatory  divisions 
of  the  fifth,  and  in  disease  of  the  middle  ear  there  may  be  loss  of  taste  in  these 
])arts  of  the  tongue,  owing  to  involvement  of  the  chorda  tympani,  the  nerve 
through  which  the  gustatory  fibres  are  distributed.  As  we  mentioned  above, 
it  seems  n(jt  improbable  that  the  fifth  nerve  subserves  the  sense  of  taste  in  the 
posterior  part  of  the  tongue  as  well. 

Perversion  of  the  sense  of  taste — parageusis — is  occasionally  met  with  in 
hysteria  and  in  the  insane.  Sid)iective  sensations  of  taste  may  be  present  as 
an  aura  preceding  the  e])ile])tic  attack  and  in  the  hallucinations  of  the  insane. 

To  test  the  sense  of  taste  various  substances  should  be  placed  up(»n  the 
tongue  in  small  cpiantities,  and  the  taste  must  be  perceived  befi)re  the  tongue 
touches  other  parts  of  the  mouth.  The  patient's  eyes  sliould  bo  closed  and  the 
following  tests  a})plied  :  for  bitter,  (juininc;  for  sweetness,  a  solution  of  sac- 
cliarine;  for  acidity,  vinegar;  for  the  saline  test,  common  salt.  An  extremely 
delicate  test  of  the  sense  of  taste  is  the  feeble  galvanic  current,  which  gives  the 
well-known  metallic  taste. 

Pneumogastric  Nerve. 
Nuclear  lesions,  eitlicr  degeneration  or  luL-uiorrhage,  occur  as  an  important 
part  r»f  bulbar  paralysis,  associated,  as  a  rule,  with  similar  changes  in  (he  spinal 
accessory  and  hvpoglossal.  ^Vithin  the  skull  the  ncr\'c-roots  may  be  com- 
j)ressed  bv  tumors,  meningeal  exudation,  or  aneurism,  in  the  neck  (he  ncrvc- 
truuk  within  the  carotid  sheath   mav  be  involved  in  aneurism   or  injured   bv 


836  DISEASES    OF    THE  NERVES. 

stab  wounds  or  compressed  by  tumors.  Occasionally  the  nerve  is  involved  in 
a  neuritis,  either  diphtheritic  or  alcoholic.  The  branches  of  distribution  are 
both  motor  and  sensory,  the  former  being  supplied  to  the  pneumogastric 
chiefly,  if  not  entirely,  througli  the  spinal  accessory.^ 

Involvement  of  the  pharyngeal  branches  which  supply  the  constrictors  and 
the  levator  palati  causes  difficulty  in  swallowing,  as  the  food  is  not  passed  on 
into  the  gullet.  Unilateral  involvement  does  not  cause  much  impairment  in 
deglutition.  Spasm  of  the  muscles  supplied  by  the  pharyngeal  branches  is  met 
with  in  hydrophobia  and  occasionally  in  hysterical  patients.  The  laryngeal 
branches  are  frequently  involved,  pai'ticularly  the  recurrents,  which,  owing  to 
their  remarkable  course,  are  liable  to  pressure  by  tumors  within  the  thorax, 
particularly  by  aneurism.  The  superior  laryngeal  nerve  is  sensory  to  the 
mucosa  and  supplies  also  the  crico-thyroid  muscle.  The  recurrent  branch 
supplies  the  mucosa  below  the  cords  and  the  other  intralaryngeal  muscles. 
The  various  forms  of  paralysis  and  spasm  will  be  described  under  the  section 
on  Diseases  of  the  Larynx.  Here  it  is  sufficient  briefly  to  mention  the  com- 
mon sequence  of  hoarseness,  loss  of  voice,  and  inability  to  cough,  owing  to 
unilateral  abductor  ])aralysis  in  involvement  of  the  recurrent  laryngeal  nerve 
by  aneurism  or  tumor. 

Bilateral  abductor  paralysis  results  occasionally  from  involvement  of  the 
spinal  accessory  nuclei  in  the  medulla  in  bulbar  paralysis  and  in  locomotor 
ataxia.  Less  frequently  it  is  produced  by  pressure  upon  both  vagi  or  both 
recurrent  nerves.  It  has  also  been  met  with  in  hysteria.  The  characteristic 
symptoms  are  difficult  respiration  and  a  prolonged  inspiratory  stridor,  with 
little  or  no  impairment  of  the  voice.  Paralysis  of  the  adductors  is  not  uncom- 
mon in  hysteria  and  causes  the  characteristic  aphonia.  It  may  follow  also 
laryngitis.     There  is  no  dyspnoea  and  no  stridor,  and  complete  loss  of  voice. 

Spasm  of  the  muscles  of  the  larynx  is  met  with  in  laryngismus  stridulus 
or  child-crowing,  in  whooping  cough,  and  in  locomotor  ataxia,  forming  the 
so-called  laryngeal  crisis.  Paroxysmal  attacks  of  laryngeal  spasm  may  occur 
in  hysteria. 

Anaesthesia  and  hyperajsthesia,  owing  to  paralysis  of  the  laryngeal  branches, 
are  rare.  The  former,  which  occasionally  occurs  in  diphtheritic  paralysis,  is  a 
dangerous  event,  as  the  particles  of  food  may  enter  tlie  glottis  and  lead  to 
deglutition-]>neumonia. 

Our  knowledge  of  the  disturbance  of  function  in  the  pulmonary  branches 
of  the  vagi  is  still  uncertain.  Motor  fibres  are  distributed  to  the  muscles  of 
the  bronchi,  spasm  of  which  is  believed  to  play  an  important  part  in  bron- 
chial asthma,  and  which  in  consequence  has  been  described  as  a  vagus  neurosis. 
Changes  in  the  respiratory  rhythm,  such  as  the  Cheyne-Stokes  breathing,  and 
the  various  forms  of  hurried  respiration  probably  depend  upon  central,  not 
peripheral,   changes. 

The  vagus  fibres  of  the  cardiac  plexus  of  nerves  subserve  motor,  sensory, 
and  probably  tro])hic  functions. 

Through  the  motor  fibres  the  inhibitory  and  regulating  impulses  pass  to  the 


AFFECTIONS    OF   THE  SPINAL    ACCESSORY  NERVE.        837 

heart,  tlie  action  of  which  in  a  few  instances,  as  in  tlie  ease  of  Colonel  Town- 
send,  can  be  slowed  at  will.  Forcible  pressure  on  both  pneninogastrics  in  the 
neck  is  followed  by  slowing  of  the  action  of  the  heart.  A  similar  effect  has 
been  produced  by  ligation  of  one  pneumogastric.  The  central  irritation  of  the 
vagus  nuclei  may  be  accompanied  with  retardation  of  the  heart's  action. 
With  complete  paralysis  of  the  vagi  the  heart's  action  is  greatly  increased. 
This  is  sometimes  seen  in  diphtheritic  paralysis.  Loss  of  the  function  of  one 
vagus  is  not,  however,  necessarily  followed  by  symptoms. 

Normally,  we  receive  no  sensory  impressions  from  the  heart  unless  it  be 
beating  at  an  unusual  rate  or  unless  the  rhythm  be  disturbed,  when  we  may 
experience  the  sensation  known  as  palpitation.  The  various  disturbances 
under  this  heading,  including  angina  pectoris,  which  is  sometimes  spoken 
of  as  a  neurosis  of  the  cardiac  branches  of  the  vagus,  will  be  considered 
in  the  section  on  Diseases  of  the  Heart. 

The  oesophageal  and  gastric  branches  preside  over  the  muscular  movements 
of  the  gullet  and  the  stomach,  and  are  concerned  in  the  act  of  vomiting  and 
in  si)asm  and  spasmodic  affections.  Gastralgia  is  in  all  probability  a  neuralgia 
of  the  branches  of  this  nerve,  though  some  attacks  may  be  due  to  cramp  in  the 
muscles  of  the  stomach.  The  gastric  crises  in  locomotor  ataxia  are  probably 
due  to  central  irritation  of  the  nuclei  of  the  spinal  accessory.  The  various 
forms  of  nervous  dyspepsia  and  the  motor  disturbances  of  the  stomach  due  to 
lesions  of  this  nerve  will  be  considered  under  the  appropriate  section.  And, 
lastly,  exophthalmic  goitre  is  sometimes  considered  as  a  neurosis  of  the  vagi. 

Spinal  Accessory  Nerve. 

The  smaller  portion  of  the  nerve  joins  the  pneumogastric  as  its  important 
motor  root.  The  larger  external  part  is  distributed  to  the  sterno-mastoid  and 
trapezius  muscles. 

The  nuclei  of  the  nerves  are  involved  in  bulbar  paralysis,  more  particularly 
the  accessory  or  internal  part.  The  nuclei  of  tlie  external  portion,  which  are 
situated  in  the  cervical  portion  of  the  cord,  may  be  involved  in  the  general 
nuclear  wasting  of  j)rogressive  muscular  atrophy.  The  nerve  may  be  com- 
j)ressed  by  tumors  or  involved  in  the  exudation  of  caries  or  meningitis,  some- 
times in  fracture.  When  within  the  skull  the  paralysis  which  results  involves 
half  of  the  soft  j)alate,  the  vocal  cord  on  the  same  side,  and  the  sterno-mastoid 
and  trapezius.  Within  the  spinal  cord  the  fibres  passing  to  these  nniscles  may 
alone  be  involved,  causing  paralysis,  which  in  the  case  of  the  trapezius  is  only 
|)artial,  as  the  lower  portion  is  innervated  by  the  cervical  nerves.  In  loss  of 
power  of  one  sterno-mastoid  the  head  is  rotated  witli  difli<'ulty  to  the  o])posite 
side.  There  is  not  necessarily  torticollis,  though  in  some  cases  the  head  is 
held  oblifjuely.  The  |)aralvsis  of  the  trapezius  is  well  indicatei]  in  (he  acts 
of  shrugging  the  shoidders  and  of  drawing  a  dccj)  breath.  I  Ih'  shoulder  on 
the  affected  side  droops  a  little  and  the  e]evati(Hi  of  the  arm  is  somewhat 
imj)aired,  since  the  traj)ezius  does  not  lix  the  scapula  as  a  jxiint  from  which 
the   deltoid    can    work.      Hilatcral   paralysi.-^  of   the   muscles  supplied   by   the 


838  DISEASES    OF    THE  NERVES.  ' 

spinal  portion  of  this  nerve  is  seen  in  some  cases  of  progressive  muscnlar 
atrophy.  When  the  sterno-mastoids  are  chiefly  involved  the  head  tends  to  fall 
backward.  If  the  trapezii  are  wasted,  the  head  drops  forward,  a  very  charac- 
teristic attitude  in  many  cases  of  this  disease.  Drooping  of  the  head  is  an 
important  symptom  in  cervical  caries  in  children.  There  are  cases  in  which 
the  child  has  (lifficulty  in  holding  up  the  head  during  the  first  year  of  life, 
due,  it  is  possible,  as  Gowers  suggests,  to  injury  of  the  accessory  nerves  during 
protracted  labor. 

The  treatment  of  these  cases  is  not  very  satisfactory.  The  paralysis  from 
nuclear  degeneration  is,  as  a  rule,  hopeless.  That  caused  by  meningeal  exu- 
dation and  due  to  pressure  from  other  causes  sometimes  disappears.  The  mus- 
cles should  be  stimulated  by  the  use  of  galvanism  and  systematic  massage. 

The  muscles  supplied  by  the  spinal  accessory  are  very  liable  to  a  spasmodic 
affection  known  as 

Torticollis,  or  Wry-neck. 

(a)  Congenital  Torticollis. — This  is  known  also  as  fixed  torticollis, 
and  is  dependent  upon  the  shortening  and  atrophy  of  the  sterno-mastoid  on 
one  side,  most  commonly  the  right.  It  is  usually  attributed  to  injury  during 
birth.  It  may  not  be  noticed  in  a  child  for  some  years  on  account  of  short- 
ness of  the  neck.  The  sterno-mastoid  on  the  affected  side  is  shortened,  hard, 
firm,  and  in  a  condition  of  more  or  less  advanced  atrophy.  This  condition 
must  not  be  confounded  with  local  thickening  of  the  sterno-mastoid  muscle 
and  the  formation  of  a  muscle  callus  following  rupture  at  birth.  In  some 
instances  the  fibrous  atrophy  involves  a  part  of  the  trapezius  muscle.  An  inter- 
esting symptom  in  this  form  of  torticollis  is  facial  asymmetry,  described  by 
Wilks,  which  may  not  be  noticed  until  the  child  is  eight  or  ten  years  old. 
Golding-Bird  suggests  that  the  facial  asymmetry  and  torticollis  are  parts  of 
a  central  affection,  the  counterpart  in  the  head  and  neck  of  infantile  spinal 
paralysis. 

(6)  Spasmodic  Torticollis. — Two  varieties  occur,  the  tonic  and  the 
clonic.  Tonic  spasm  is  usually  limited  to  the  muscles  of  one  side  :  the  occiput 
is  drawn  toward  the  shoulder  of  the  affected  side,  the  face  is  rotated  toward 
the  opposite  shoulder,  and  at  the  same  time  the  chin  is  raised.  When  the  tra- 
pezius is  affected,  the  depression  of  the  head  toward  the  same  side  is  more 
marked,  and  the  siioulder  is  also  raised  by  its  action.  In  long-standing  cases 
the  muscles  are  very  prominent  and  rigid.  Both  muscles  are  rarely  involved 
in  the  tonic  form.  The  splenius  capitis  may  be  involved  alone,  or  more  com- 
monly with  the  sterno-mastoid. 

The  clonic  form  is  much  more  distressing.  The  jerking  contractions  recur 
every  few  minutes,  either  in  the  sterno-mastoid  alone  on  one  side  or  more  fre- 
quently in  several  of  the  cervical  muscles,  particularly  tlie  splenius  and  the 
trapezius.  More  rarely  the  muscles  on  both  sides  are  involved.  There  are 
instances  of  rotatory  spasm  of  the  head,  due  prol)al)ly  to  clonic  contractions 
of  the  obliquus  capitis.     In  other  cases  there  is  a  nodding  spasm,  in  which  the 


AFFECTIOys    OF    THE   HYPOGLOSSAL    XERVE.  839 

deopiT-placecl  m-ti  capitis  miisclcs  are  involval.  Tlio  spasm  not  infrequently 
extends,  and  involves  the  muscles  of  the  face,  and  even  those  of  the  arms. 

The  disease  is  most  common  in  adults.  In  females  it  mav  be  an  hvstencal 
manifestation.  Cases  have  followed  exposure  to  cold  or  have  resulted  Ironi 
injury  tc  the  necU.  In  the  majority  of  instances  the  cause  of  the  disease  is 
obscure,  and  nothino-  reallv  is  known  of  its  essential  nature.  It  is  reo-arded 
as  a  functional  neurosis,  but  it  is  possil)ly  ilue  to  disturbance  in  the  cortical 
centres  presidino-  over  the  nuiscles.  Cold  is  i)t'lieved  by  some  to  have  an 
important  influence,  and  eases  have  been  described  as  rheumatic  torticollis. 

The  disease  must  be  distinguished  from  the  nodding  spasm  of  ei)ilepsy, 
which  is  usually  seen  in  young  children,  accompanied  with  slight  loss  of  con- 
sciousness. There  is  also  seen  in  children  about  the  time  of  dentition  a  uni- 
lateral jerking  of  the  head  from  side  to  side,  which,  as  a  rule,  is  not  of  any 
special  signiticance.  Spasm  of  the  muscles  of  the  neck  occurs  in  cervical 
caries,  usually  associated  with  tenderness  over  the  spines  :  examination  of  the 
pharynx  may  reveal  swelling  and  tenderness  beneath  the  anterior  ligament. 

The  disease  varies  greatly  in  its  course.  A  majority  of  the  cases  persist  for 
a  long  time,  and  too  often  the  cure  is  only  temporary. 

Treatment. — In  the  tonic  form  section  of  the  muscle  with  the  application 
of  a  suitable  apparatus  may  effect  a  cure.  In  the  clonic  variety  fixation  of 
the  head  mechanically  can  rarely  be  borne.  Drugs  are  of  little  or  no  value, 
though  it  is  stated  that  very  large  doses  of  potassiiun  bromide  lessen  the  inten- 
sity of  the  spasm.  Morphine,  which  has  been  highly  recommended,  should 
be  employed  with  great  care.  Electricity  has  been  warmly  recommended. 
Counter-irritation,  particularly  with  the  thermo-cautery,  may  be  tried.  In 
very  obstinate  cases  surgical  measures  may  be  em})loyed,  and  division  or 
stretching  of  the  nerve  and  section  of  the  muscle  have  been  resorted  to, 
sometimes  with  benefit :  as  a  rule  the  condition  recurs.  Personally,  I  have 
not  seen  a  permanent  cure  in  any  case  of  spasmodic  torticollis. 

Hypoglossal  Nerve. 

This  is  the  motor  nerve  of  the  tongue  and  for  the  extrinsic  muscles  except 
the  mylo-hyoid  and  digastric.  The  cortical  centre  is  in  the  lower  part  of  the 
ascending  frontal  gyrus. 

Paralysis. — This  may  follow  a  lesion  of  the  cortical  centre,  as  in  hemi- 
plegia, with  which  it  "vvill  be  considered,  or  is  due  to  affection  of  the  nuclei  in 
the  medulla  oi'  to  involvement  of  the  nerve  in  its  eoiii'se.  Nuclear  disease  is 
usually  part  of  a  l)ulbar  paralysis,  and  is  bilateral  and  associated  w  ith  par- 
alysis of  the  lips  and  ])harynx.  Speech  is  greatly  impaired,  as  the  linguals 
and  dentals  eniniot  l)e  ])rononneed.  Mastication  \un\  deglutition  are  p<'rforme(l 
with  dillieulty.  The  tongue  usually  wastes  and  there  aic  lii)rillary  tremors. 
The  nnicous  membrane  is  thrown  into  folds,  and  in  extreme  eases  the  tongue 
lies  motionless  in  tlu;  floor  of  the  nidiitl)  :in(l  (■•■innot  i»r  prodiidcd.  l^nilateral 
paralvsis  and  atrophv  more  commonly  fdlow  involvenicnt  ol'llic  nerve  outside 
the  nucleus^  due  to  meningitis,  syphilis,  tumors,  or  caries,  s(»metimes  following 


840  DISEASES    OF   THE  NERVES. 

injuries  of  the  neck  and  jaw.  The  atrophy  is  usually  marked,  and  the  mucous 
membrane  on  the  affected  side  is  thrown  into  folds.  When  protruded  the 
tongue  is  pushed  toward  the  affected  side.  The  cases  are  rare.  Birkett  in 
a  description  of  a  remarkable  instance  states  that  he  iias  only  been  able  to 
collect  thirteen  cases  in  the  literature.  In  his  patient  the  paralysis  resulted  from 
inflammatory  changes  about  the  cervical  glands  at  the  angle  of  the  jaw ;  and 
in  such  cases  there  may  also  be  involvement  of  other  nerves. 

The  diagnosis  is  rarely  difficult.  In  supranuclear  paralysis  there  is  associa- 
ted hemiplegia  ;  the  muscles  do  not  waste  and  there  are  no  electrical  changes. 
The  nuclear  disease  is  almost  invariably  bilateral  and  part  of  a  bulbar  paral- 
ysis. The  muscles  waste  and  the  reaction  of  degeneneration  is  present.  Uni- 
lateral paralysis  and  atrophy  are  most  common  in  infranuclear  lesions. 

Spasm. — Tiiis  may  involve  one  or  both  sides,  and  is  usually  part  of  some 
convulsive  disorder,  either  chorea  or  facial  spasm.  It  may  occur  in  hysteria, 
and  cases  are  said  to  result  from  reflex  irritation  in  the  fifth  nerve.  It  is  not 
uncommon  to  see  the  tongue  protruded  in  a  spasmodic  manner  just  before  the 
explosive  utterance  of  words  in  stuttering.  There  are  cases  of  clonic  spasm  in 
which  the  tongue  is  thrust  in  and  out  forty  or  fifty  times  a  minute.  The 
spasm  in  these  instances  may  be  unilateral. 

The  prognosis  is  good,  as  the  spasm  is  rarely  due  to  organic  disease. 

The  treatment  of  jiaralysis  of  the  hypoglossal  nerve  is  rarely  successful, 
except  in  the  cases  of  unilateral  disease  due  to  syphilis.  When  due  to  bulbar 
atrophy  it  is  incurable. 


LESIONS  OF  THE  SPINAL  NERVES. 

Cervical  Plexus. 

(1)  Oceipito-cervical  Neuralgia. — This  involves  the  occipitalis  major  and 
minor  and  the  auricularis  magnus  nerves.  The  patient  complains  of  pains 
in  the  neck,  in  the  occiput,  and  in  the  ear,  which  sometimes  radiate  to  the  face 
and  to  the  arm.  It  usually  follows  cold,  and  may  be  associated  with  a  stiff 
neck  or  with  torticollis.  Occasionally  it  is  caused  by  pressure,  as  in  carrying 
a  heavy  load  on  the  nt^ck.  Painful  points  may  be  present  midway  between 
the  mastoid  processes  and  the  spine. 

Tlie  prognosis  is,  as  a  rule,  good  except  when  the  neuralgia  is  due  to  dis- 
ease of  the  cervical  vertebrse.  Occasionally  in  sypliilis  there  is  a  cervico- 
occipital  neuralgia,  which  yields  readily  to  iodide  of  potassium. 

(2)  Phrenic  Nerve. — In  the  neck  the  nerve-trunk  is  occasionally  divided  by 
])unctured  wounds,  and  in  tlie  thorax  compressed  by  tumors  and  by  aneurism. 
Paralysis  follows  involvement  of  the  motor  centres  in  the  cervical  cord  in 
progressive  muscular  atrophy.  It  may  also  result  from  lead-poisoning  and 
neuritis.  Owing  to  the  inaction  of  the  diaphragm,  res])iration  is  carried  on 
by  the  intercostal  and  accessory  muscles,  the  movements  of  the  thorax  are 
increased,  and  the  abdomen  is  retracted  instead  of  being  pushed  out  during 
inspiration.     When  the  patient  is  quiet  and  at  rest  there  may  be  very  slight 


AFFECTIONS    OF    TIIF   BRACHIAL    PLEXUS.  841 

disturbance,  but  on  exertion  tiie  respiration  is  (juiekened  aiul  there  may  be 
dyspnoea.  When  paralyzed  on  one  side  only,  inspiration  nuiy  show  thai  the 
descent  of  the  diaphragm  is  much  less  on  one  side.  The  diflieulty  of  coughing 
and  expelling  the  mucus  renders  pulmonary  complications  very  dangerous. 

The  diagnosis  is  not  always  easy.  In  hysterical  women  the  breathing 
may  be  entirely  thoracic  and  the  diaphragm  scarcely  moves  during  inspiration. 
Immobility  of  the  muscle  is  present  in  diaphragmatic  pleurisy  and  in  large 
purulent  effusions.  The  muscle  may  itself  be  degenerated,  and  instances  are 
recorded  by  Callender  of  primary  degeneration  of  the  muscle-tibres. 

The  prognosis  is  unfavorable  in  the  cases  due  to  neuritis.  W.  Pasteur 
states  that  of  15  cases  following  diphtheria,  only  8  recovered.  A  serious  risk 
is  in  the  tendency  to  oedema  and  engorgement  of  the  bases  of  the  lung,  owing 
to  the  lessened  action  of  the  diaphragm. 

The  treatment  is,  as  a  rule,  that  of  neuritis.  Galvanism  of  the  phrenic 
nerve  may  be  tried  :  one  pole  may  be  placed  just  outside  the  lower  part  of  the 
clavicular  portion  of  the  sterno-mastoid,  and  the  other  at  the  epigastrium. 

Spasm  of  the  diaphragm  may  be  either  tonic  or  clonic.  The  former  is 
stated  to  occur  sometimes  and  to  be  the  cause  of  death  in  tetanus.  Clonic 
spasm  of  the  diaphragm  causes  hiccough  or  singultus.  This  may  be  a  func- 
tional disorder,  as  in  hysteria,  but  the  spasm  is  not  infrequently  excited  by  the 
direct  action  of  hot  substances  as  they  pass  through  the  oesophageal  opening 
of  the  diaphragm.  Occasionally  it  arises  from  reflex  irritation  in  the  stomach 
or  intestines,  as  in  dysentery,  cholera,  and  peritonitis.  It  may  be  caused  by 
direct  irritation  of  the  phrenic  nerve  in  its  course.  Much  more  rarely  it  is 
due  to  central  irritation.  In  chronic  alcoholism  and  in  uraemia  it  may  be  a 
persistent  and  even  dangerous  symptom.  In  lead-poisoning  it  may  occur 
without  any  obvious  cause,  and,  persisting  day  and  night,  may  prove  fatal. 

Though  rarely  causing  alarm,  protracted  cases  in  delicate  or  elderly  people 
may  be  serious  and  very  dillicult  to  relieve. 

Amono-  remedies  which  mav  be  tried  are  inhalations  of  nitrite  of  amyl, 
which  usually  relieves  with  great  promptness,  and  the  good  effect  may  be  kept 
up  bv  the  administration  of  nitro-glyccrin  in  the  intervals.  InhalaticMis  of 
<;hloroform  ciieck  the  spasm  at  once,  though  usually  only  for  a  time.  The 
hypodermic  injection  of  a  quarter  to  a  third  of  a  grain  of  morphine  may  be 
necessary  to  procure  sleep.  Nothing  relieves  the  persistent  hiccough  of  acute 
alcoholism  better  than  a  hypodermic  injection  of  apomorphine.  The  hysteri- 
cal form  rarely  resists  the  static  electricity. 

Brachial  Plexus. 
The  nojrves  mav  be  involved  above  or  IhIow  the  clavicli — in  the  Ibrmer 
situation  by  direct  injury,  tumors,  and  other  atlections  of  the  neck.  The  infra- 
clavicular portion  is  siH'cialiy  liablf  to  injury  in  dislocation  of  the  shoulder, 
the  strain  of  a  sudden  wrench  orilicarm,  in  l;i«(  r:iti(<M  i.y  a  iVactiirc,  and  more 
rarely  in  an  ascending  neuritis.  Injury  to  {\\r  \\vv\r>  in  (lie  operation  of  turn- 
ing is  not  an  uncommon  form  of  the  so-calle<l  obstetrical  palsy. 


842  DISEASES    OF    THE   NERVES. 

The  paralysis  following  dislocation  of  the  shoulder,  more  especially  the 
subcoracoid  form,  is  particularly  important.  When  the  luxation  i.s  quickly 
reduced  the  symptoms  disappear  in  a  short  time.  In  other  cases,  in  which 
the  dislocation  has  existed  for  some  time,  every  muscle  of  the  arm  may  be 
paralyzed.  Very  serious  indeed  are  the  cages  in  which  the  dislocation  is  unde- 
tected and  remains  unreduced  for  some  time,  as  the  prolonged  pressure  on  the 
plexus  may  cause  complete  and  permanent  paralysis,  with  wasting  of  the 
muscles,  contractures,  and  trophic  changes  of  the  skin.  The  medico-legal 
aspect  of  these  cases  is  most  important,  and  the  practitioner  should  be  on  his 
guard  against  suits  for  damages  which  may  be  brought  in  case  of  permanent 
disability.  In  rare  instances  this  may  follow  direct  injury  in  the  region  of  the 
shoulder  without  dislocation  and  apparently  without  fracture.  The  dislocation 
may  be  set  at  once,  but  the  damage  to  the  plexus  results  in  permanent  jiaral- 
ysis  of  certain  of  the  nerve-trunks.  In  one  instance  seen  by  the  writer  the 
surgeon  reduced  the  dislocation,  but  subsequently  the  head  of  the  bone  slipped 
out  of  the  socket,  and  the  patient  was  not  seen  again  until  irreparable  damage 
had  been  done. 

The  obstetrical  cases  have  very  considerable  interest,  and  have  been  studied 
by  Duchenne  and  by  Erb,  whose  name  this  form  of  paralysis  sometimes  bears. 
The  muscles  involved,  as  a  rule,  are  the  deltoid,  the  biceps,  the  supraspinatus, 
infraspinatus,  the  brachialis  anticus,  and  supinator  longus.  The  lesion  is  often 
not  noticed  for  some  days  after  birth,  when  the  nurse  or  mother  calls  the 
attention  of  the  physician  to  the  fact  that  one  arm  of  the  child  hangs  loosely 
by  its  side.  The  movements  of  the  wrist  and  of  the  fingers  are  unaifected, 
and  the  forearm  can  be  extended  upon  the  arm,  but  the  arm  cannot  be  lifted. 
At  first  not  much  difference  can  be  noticed  in  the  size  of  the  arm,  as  the  sub- 
cutaneous fat  is  well  developed.  The  nerves  involved  are  the  fifth  and  sixth. 
It  is  particularly  liable  to  occur  in  the  extraction  of  the  head  in  breech 
delivery,  and,  according  to  Starr,  in  the  majority  of  the  cases  the  injury 
is  done  by  pressure  of  the  fingers  of  the  obstetrician.  In  other  instances 
it  is  caused  by  pressure  of  the  forceps  or  traction  on  the  arm  in  version. 
The  outlook  is,  as  a  rule,  good,  but  occasionally  the  loss  of  power  remains  in 
some  of  the  muscles. 

Brachial.  Neuritis  is  a  very  important  affection  which  may  either  follow 
a  neuritis  of  one  of  the  branches  or  be  primary  in  the  plexus.  The  ascending 
neuritis  usually  follows  an  injiny  of  one  of  the  peripheral  nerves,  and  is  asso- 
ciated with  great  pain  and  with  wasting  of  the  muscles. 

The  primary  form  is  a  perineuritis  of  the  sheaths  of  the  brachial  cord, 
and  is  an  affection  "  so  closely  analogous  to  sciatica  that  it  may  be  called 
sciatica  of  the  arm  "  (G(nvers).  Some  of  the  cases  would  indicate  rather  that 
the  nerve-roots  were  involved,  as  there  is  nuicli  ])ain  about  the  spine.  The 
affection  is  met  with  chiefly  in  females  after  filty,  particularly  in  persons  of 
a  full  habit  who  have  had  gouty  manifestations.  The  pain  is  severe,  and  felt 
either  in  the  plexus  itself  or  along  the  course  of  the  nerves  of  the  arm,  more 
rarely  about    the  shoulder  and    beneath  the    scapula.     It    may  come   on    in 


AFFECTIOXS    OF    THE   BRACHIAL    PLEXUS.  843 

paroxysms,  ami  is  often  described  as  a  burning  soreness  accompanied  witli 
tingling  of  the  skin.  There  is  rarely  great  wasting  of  the  mnscles,  though 
there  is  pain  on  motion.  There  may  be  slight  oedema  of  the  hands  and 
glossiness  of  the  skin  ;  occasionally  arthritis.  Tlic  condition  mu^t  be  distin- 
guished from  the  humeral  periarthritis  with  atrophy  of  the  muscles  and  neur- 
algic pains. 

Lesions  of  the  Individual  Nerves  of  the  Brachial  Plexus. 

(rt)  Long  Thoracic  Nerve  (Serratus  Pai.sy).— Tiiis  is  met  with 
chiefly  in  men  as  a  result  of  injury  to  the  nerve  in  the  neck  by  direct  pressin-e, 
as  in  carrying  a  heavy  load,  rarely  in  consequence  of  long-continued  effort 
with  the  arm  raised,  as  in  whitewashing  a  ceiling;  more  rarely  it  is  due  to 
cold.  In  progressive  muscuhu'  atrophy  and  in  acute  poliomyelitis  anterior 
the  serratus  may  be  involved  with  other  mnscles.  The  paralysis  is  readilv 
recognized  by  the  position  of  the  scapula,  the  inferior  angle  of  which  is  nearer 
the  spine,  owing  to  the  unopposed  action  of  the  rhomboid  and  of  the  levator 
anguH  scapulfe.  The  posterior  border  projects,  so  that  the  scapula  looks 
winged,  which  is  particularly  noticeable  wlien  the  arm  is  moved  forward. 
As  a  rule,  the  fingers  can  be  readily  inserted  under  the  margin. 

The  affection  runs  a  slow  course,  and  it  may  be  months  before  the  condition 
improves. 

{b)  Circumflex  Nerve. — This  is  apt  to  be  involved  in  injuries,  in  dis- 
locations, and  is  sometimes  bruised  in  the  use  of  a  crutch.  It  may  be  paralyzed 
also  by  neuritis  and  by  pressure  during  acute  illness.  The  nerve  supplies  the 
deltoid  and  teres  minor  muscles  and  the  skin  over  the  former  muscle.  In  con- 
serpience  of  paralysis  of  the  deltoid  the  arm  cannot  be  raised,  and  the  wasting 
which  usually  follows  changes  materially  the  shape  of  the  shoulder.  In  time 
the  articular  ligaments  become  relaxed,  and  there  may  be  a  distinct  space 
between  the  head  of  tiie  lumierus  and  the  acromion.  In  other  instances 
trophic  changes  occur  about  the  joints,  such  as  tiiickening  of  the  b'gaments 
and  adiicsions,  resulting  at  last  in  a  condition  not  unlike  ankylosis.  Aiucs- 
tlicsia  of  the  skin  over  the  muscle  is  not  always  present. 

{(■)  Mi:scuLo-Ki»iHAL  Paralysis;  Radial  Paralysis  (Sleep  Pal- 
sies).— Tiie  exp)sed  position  of  the  musculo-spiral  nci-vc  as  it  leaves  the 
])Iexus  to  wind  round  the  bone  makes  it  liable  to  injury,  particularly 
in  fracture.  l>rui>ing  of  this  nerve  in  the  use  of  the  crutcli  is  the  coiu- 
monest  cause  of  the  so-called  "crutch-palsy."  A  still  ni(»re  fre(|uent 
cause  is  pressure  during  sleep  when  the  arm  is  hanging  over  the  back 
of  a  <'hair,  or  j)ressure  of  the  l)<)d\-  ii|tuii  the  arm  when  a  person  is  sleej)- 
ing  on  a  liaid  Ix'uch  oi"  on  the  ground.  XeuiMtis  due  to  cold  oi'  an  infec- 
tious (^lisease  is  a  less  cdinmon  cause,  and  some  of  the  eases  att  I'ibiited  t(t 
these  are  reallv  due  to  pressure.  Dii-ed  iiiiiseular  actimi,  :is  in  (liiowiiig  a 
stone  or  a  erieket-ball  violentlv,  iiiav  eoinplefely  paralyze  ilir  iicr\-e.  Transient 
])alsy  mav  be  (-aiised  by  the  accidental  pimetniv  n['  the  iicrve  in  ;i  liypitdermi(! 
injection.      The  common  paralysis  of  lead-pni.-oning   is  the   result  ot"  involve- 


844  DISEASES    OF    THE   NERVES. 

ment  of  branches  of  this  nerve.  A  complete  lesion  of  the  musculo-spiral 
high  up  causes  paralysis  of  the  triceps,  the  brachialis  anticus,  both  supinators, 
and  the  extensors  of  the  wrists  and  fingers.  In  a  lesion  about  the  elbow  the 
arm-muscles  and  the  supinator  longus  are  spared.  In  the  pressure  palsies, 
as  a  rule,  the  supinators  are  involved.  The  characteristic  feature  of  this 
paralysis  is  the  wrist-drop  and  the  inability  to  extend  the  first  phalanges  of 
the  fingers  and  thumbs.  If  the  forearm  be  extended,  the  hand  droops  and 
cannot  be  raised,  nor  can  the  fingers  or  thumbs  be  extended.  If,  however, 
the  hand  and  the  first  phalanges  are  supported,  the  action  of  the  interossei 
and  the  lumbricales  then  extend  the  middle  and  terminal  phalanges.  Sensa- 
tion is  not  always  affected.  There  may  be  numbness  or  tingling,  but  rarely 
complete  anaesthesia.  Musculo-spiral  palsy  is  readily  recognized,  though  it 
may  be  difficult  sometimes  to  assign  the  proper  cause.  The  pressure  palsies 
are,  as  a  rule,  unilateral,  and  involve  the  nerve  high  enough  to  include  the 
supinator  longus.  In  the  neuritis  from  lead  the  affection  is  bilateral,  as  it  is 
also  in  the  alcoholic  form,  both  of  which  are  recognized  easily  by  their  con- 
comitant features. 

The  outlook  is  good,  particularly  in  the  pressure  cases,  in  which  the 
paralysis  may  disappear  in  a  few  days.  The  electrical  examination  is  of  the 
greatest  importance  in  the  prognosis,  and  the  rules  apply  which  are  laid  down 
in  paralysis  of  the  facial. 

{(1)  Paralysis  of  the  Ulnar  Nerve. — The  ulnar  supplies  by  its  motor 
branches  the  ulnar  halves  of  the  deep  flexor  of  the  fingers,  the  muscles  of  the 
little  finger,  the  interossei,  the  ulnar  flexor  of  the  wrist,  and  the  adductor  and 
short  head  of  the  inner  flexor  of  the  thumb.  The  sensory  distribution  is  to 
the  ulnar  side  of  the  hand,  including  two  and  a  half  fingers  on  the  back  and 
one  and  a  half  fingers  on  the  front.  The  paralysis  occasionally  results  from 
pressure,  more  commonly  from  prolonged  flexion  of  the  elbow,  as  in  sleep  and 
in  illnesses.  The  hand  deviates  a  little  to  the  radial  side,  owing  to  paralysis 
of  the  ulnar  flexor  of  the  wrist.  Flexion  of  the  first  phalanges  is  impossible, 
and  also  adduction  of  the  thumb.  In  long-standing  cases  the  first  phalanges 
become  very  extended  and  the  others  strongly  flexed,  producing  the  so-called 
claw-hand  or  main  en  griffc  The  loss  of  sensation  is  in  the  distribution 
already  mentioned. 

(e)  Paralysis  of  the  Median  Nerve. — The  motor  distribution  is  to 
the  radial  flexor  of  the  wrist,  the  flexors  of  the  fingers  with  the  exception  of 
the  idnar  half  of  the  deep  flexors,  the  abductor  and  flexors  of  the  thumb,  the 
radial  lumbricales,  and  the  pronators  of  the  wrist.  The  sensory  branches  sup- 
ply the  radial  side  of  the  palm,  the  front  of  the  thnmb,  the  first  two  fingers, 
half  of  the  third  finger,  and  the  skin  on  the  back  of  these  three  fingers.  This 
nerve  is  seldom  paralyzed  alone.  It  may  be  involved  in  fracture  and  occa- 
sionally in  neuritis,  and  very  rarely  by  violent  contraction  of  the  pronator 
teres.  The  wrist  in  flexion  is  drawn  strongly  to  the  ulnar  side,  and  the  thumb 
cannot  be  opposed  to  the  tips  of  the  finger.  The  second  phalanges  cannot  be 
flexed  on  the  first  nor  the  distal  phalanges  on  tlie  second,  but  in  the  third  and 


AFFECTIOXS  OF  THE  THORACIC  AND  DORSAL  NERVES.    845 

fourth  finger??  this  can  be  performed  hy  tlie  uhiar  half  of  the  flexor  profundus. 
When  the  sensation  is  involved  it  follows  the  distribution  of  the  fibres,  as 
alreadv  mentioned.  The  wastinn;  of  the  thumb-muscles  forms  a  striking:  cha- 
racteristic  in  this  form  of  paralysis.  The  skin  may  be  glossy  and  the  nutrition 
of  the  nails  impaired. 

Thoracic  and  Dorsal  Nerves. 

The  anterior  branches  of  the  twelve  dorsal  nerves  supply  the  intercostal 
muscles,  the  levatores  costarum,  the  abdominal  muscles,  and  the  serrati  postici. 
The  sensory  branches  supply  the  skin  in  the  antero-lateral  region  of  the  thorax 
and  abdomen.  The  posterior  branches  of  the  dorsal  nerves  supply  the  deep  mus- 
cles of  the  back  and  the  skin  over  the  same. 

Affections  of  these  branches  are  not  very  frequent,  except  of  the  intercostal 
nerves,  which  are  the  subject  of  an  intractable  form  of  neuralgia. 

Intercostal  nenrahjia  occurs  most  commonly  in  women,  and  involves  the 
nerves  from  the  third  to  the  ninth,  most  frequently  the  seventh,  eighth,  and 
ninth  on  the  left  side.  The  cases  are  most  common  in  anaemic,  overworked 
women.  The  nerves  may  be  involved  by  aneurism  or  tumor,  occasionally  in 
chronic  pleurisy,  or  in  the  adhesions  of  long-standing  tuberculosis,  or  in  caries 
of  the  spine.  Though  usually  constant,  the  pain  is  subject  to  marked  exacer- 
bations, and  may  be  very  severe ;  movements  such  as  coughing  and  deep  inspi- 
ration aggravate  it  very  greatly.  Tender  points  are  usually  jiresent  at  the 
intervertebral  foramen,  one  near  the  sternum,  one -over  the  rectus  muscle,  and 
a  third  midway  between  these.  The  neuritis  causing  neuralgia  is  often  accom- 
panied with  an  eruption  of  herpes  zoster,  forming  the  so-called  "shingles." 
The  pain  may  be  most  intense  prior  to  the  outbreak  of  the  rash,  and  in  some 
instances  persists  long  after  its  disappearance. 

The  diagnosis  of  intercostal  neuralgia  is  usually  easy,  though  sj>ecial  <'are 
must  be  taken  to  exclude  the  presence  of  spinal  caries,  of  aneurismal  tumor, 
and  of  pleurisy.     Many  cases  prove  very  intractable. 

A  special  form  is  the  neuralgia  of  the  branches  passing  to  the  breast — 
mastodynia.  It  is  seen  most  commonly  shortly  after  ])uberty  in  auicmi*'  and 
hysterical  girls.  The  pain  may  be  very  severe,  either  localized  or  involving 
the  entire  breast.  Occasionally  small  hard  nodules  are  felt  beneath  the  skin. 
The  condition  may  follow  prolonged  lactation. 

Paralysis  of  the  muscles  supplied  l)y  the  thoracic  and  dorsal  nerves  is 
rarely  seen  alone,  and  in  cases  of  hcmii)legia  they  arc  not  involved,  the  imis- 
clesof  both  sides  being  innervated  from  either  hemisphere  (Broadbent).  Tn 
the  forms  of  primarv  nuiscidar  atro])hy  the  weakness  of  the  back  mus<'les  is 
very  striking,  and  the  attitude  of  the  child,  with  marked  arching  of  the  lum- 
bar vertebne,  prominence  of  the  alxlonicn,  and  arching  backward  of  the  back, 
forms  a  very  characteristic  i)ictnre.  In  getting  up  from  the  floor  the  child 
has  to  lift  his  body  <.n  the  arms  and  gradually  climb  up  his  legs,  as  in  the 
familiar  j)icture  in  Gowers'  work. 


«46  DISEASES    OF    THE   NERVES. 

Lumbar  and  Sacral  Plexuses. 

The  lumbar  plexus,  made  up  of  looj).^  of  communi(;ation  between  the 
anterior  branches  of  the  four  upper  lumbar  nerves^  supplies  the  flexors  and 
adductors  of  the  hip-joint,  the  extensors  of  the  feet,  and  the  cremaster.  The 
sensory  fibres  are  distributed  to  the  skin  of  the  lower  part  of  the  abdomen,  the 
antero-lateral  region  of  the  thigh,  and  the  inner  side  of  the  leg  and  foot. 

The  cords  of  the  plexus  itself  are  sometimes  involved  by  tumors  of  the 
Ivmph-glands,  in  psoas  abscess,  and  in  caries  of  the  vertebrae.  Affections  of 
the  individual  nerves  of  the  lumbar  ])lexus  are  not  so  common. 

The  anterior  crural  nerve  may  be  ijivolved  in  \\'ounds,  in  psoas  abscess, 
and  in  disease  of  the  vertebras,  stretched  in  dislocation  of  the  hip-joint,  or 
invaded  by  pelvic  tumors.  When  paralyzed  there  is  loss  of  power  in  the 
extensors  of  the  knee,  and  if  the  nerve  is  involved  high  up  there  may  be  loss 
of  power  in  the  psoas  muscle.  In  prolonged  involvement  the  muscles  waste 
and  walking  may  be  difficult  or  impossible.  There  is  anaesthesia  of  the 
greater  ]iorti(jn  of  the  skin  of  the  thigh,  except  a  narrow  strip  at  the  back 
jiart,  and  in  the  distribution  of  the  internal  saphenous  nerve  along  the  inner 
side  of  the  leg  to  the  big  toe.  Neuralgia  of  the  crural  nerve  is  not  very  com- 
mon, apart  from  the  ])ressure  symjitoms  due  to  tuniors  and  growths  about  the 
spine.  The  pain  is  in  the  antero-internal  portion  of  the  thigh  and  knee  and 
extends  along  the  inner  surface  of  the  leg  and  foot.  There  is  often  a  painful 
spot  where  the  nerve  emerges  below  Poupart's  ligament. 

The  obturator  nerve  is  occasionally  injured  during  parturition.  When  par- 
alyzed there  is  loss  of  power  in  the  adductors  of  the  thigh,  and  the  ])atient 
cannot  cross  one  leg  over  the  other.  Owing  to  involvement  of  the  obturator 
externus,  rotation  inward  of  the  thigh  is  not  well  performed. 

There  are  troublesome  neuralgias  of  certain  branches  of  the  lumbar  plexus. 
There  may  be  pain  in  the  course  of  the  ilio-inguinal  and  ilio-hypogastric 
nerves,  in  the  neighborhood  of  the  crest  of  the  ilium,  and  in  the  external 
abdominal  ring.  The  ilio-inguinal  nerve,  which  accompanies  the  spermatic 
cord  through  the  inguinal  canal  and  escapes  at  the  external  abdominal  ring,  is 
distributed  to  the  skin  of  the  upper  and  inner  part  of  the  thigh  and  to  the 
scrotum.  There  are  instances  in  which  the  distribution  of  this  nerve  is  the 
seat  of  very  severe  pain,  and  the  affection  known  as  the  irritable  testis  of 
Cooper  is  believed  to  be  an  affection  of  this  nerve.  Associated  with  this  i)ain 
there  may  be  sensations  of  fainting  and  the  sickening  feeling  such  as  is  felt  on 
compression  of  the  testis. 

Sacral  Plexus. — This  is  still  more  likely  to  be  damaged  by  pelvic 
tumors  and  various  affections  of  the  pelvic  bones.  The  branches  may  be 
injured  during  parturition.  Neuritis  is  not  uncommon,  and  is  frequently  an 
extension  from  the  sciatic. 

Of  the  branches,  the  sciatic  nerve  when  paralyzed  causes  loss  of  power  in 
the  flexors  of  the  leg  and  in  the  muscles  below  the  knee.  An  affection  or 
injury  below  the  middle  thigh  involves  only  the  muscles  of  the  leg  proper. 


AFFECTIOXS  OF  THE  LUMBAR  AXD  SACRAL  PLEXUSES.   847 

Tliere  is  an8esthe;?ia  of  the  oiitor  half  of  tlie  leg,  the  sole,  and  the  greater  por- 
tion of  the  dorsum  of  the  foot.  Tlie  niiiseles  frequently  waste  and  there  may 
be  trophic  disturbances.  In  paralysis  of  one  sciatic  nerve  the  leg  is  fixed  at 
the  knee  by  the  action  of  the  (juadrieeps  extensor.  Paralysis  of  the  small 
sciatic  nerve  is  rarely  seen.  Tlie  gluteus  maxinuis  is  involved,  there  is  dif- 
ficulty in  rising  from  a  seat,  an  I  there  is  usually  a  strip  of  anesthesia  on 
the  back  part  of  the  thigh  in  the  region  of  distribution  of  the  cutaneous 
branches.  Of  the  branches  of  the  sciatic  nerve,  the  external  popliteal  when 
jiaralyzed  causes  loss  of  power  in  the  peronei,  the  long  extensor  of  the  toes,  the 
tibialis  anticus,  and  the  extensor  brevis  digitorum.  As  a  result  there  is  a  foot- 
drop,  the  ankle  cannot  be  flexed,  and,  as  the  toes  cannot  be  raised  from  the 
ground  in  walking,  the  whole  leg  is  lifted,  producing  the  characteristic  step- 
page gait  seen  in  so  many  forms  of  peripheral  neuritis.  In  long-standing  cases 
the  foot  is  permanently  extended  and  there  is  wasting  of  the  anterior  tibial  and 
])eroneal  muscles.  The  loss  of  sensation  is  in  the  outer  Jialf  of  the  front  of  the 
leg  and  on  the  dorsum  of  the  foot. 

Paralysis  of  the  internal  popliteal  nerve  causes  loss  of  power  in  the  gas- 
trocnemius, the  ])lantaris,  soleus,  popliteus,  the  tibialis  posticus,  the  long  and 
short  flexors  of  the  toes,  and  the  muscles  of  the  sole  of  the  foot.  The  foot 
cannot  be  adducted  nor  can  the  patient  rise  on  tiptoe.  In  long-standing  cases 
talipes  calcaneus  follows,  and  the  toes  assume  a  claw-like  })osition  from  sec- 
ondary contracture. 

Among  other  neuralgic  affections  of  the  lumbar  and  sacral  ])lexuses  are  the 
following:  coccygodynia,  an  affection  most  common  in  women.  The  pain 
about  the  coccyx  is  greatly  aggravated  by  the  sitting  ])osture,  and  is  usu- 
ally associated  with  other  nervous  phenomena.  It  is  an  extremely  intractable 
affection,  and  the  condition  may  be  so  intolerable  that  resection  of  the  coccyx 
has  to  be  performed — an  operation  whichj  however,  is  not  always  successful  in 
relieving  the  pain. 

There  are  certain  neuralgic;  affections  of  the  nerves  of  the  feet  which  are 
very  troublesome.  In  the  affection  known  as  ])ainful  heel,  flic  pododynia  of 
S.  D.  Gross,  the  pain  is  usually  most  severe  in  the  heel  itself,  sometimes  in  a 
very  limited  spot  on  the  under  surface,  sometimes  in  the  line  of  the  metatarso- 
phalangeal joint.  It  is  most  common  in  women,  and  is  not  necessarily  asso- 
ciated with  any  swelling,  discoloration,  or  enlargement  of  the  joint.  In  some 
instances  it  would  apj)ear  to  be  a  manifestation  of  hysteria  ;  in  others  the 
]>atients  have  rheumatism  or  gout.  Some  of  the  worst  cases  occur  in  shoj)- 
girls  as  a  residt  of  standing  for  a  long  lime  on   the  fix't. 

Plantar  neuralgia  may  be  assfx-iafcd  wilii  a  dclinitc  neui'itis,  and  is  some- 
times seen  after  the  s])ecific  fevers,  and  has  been  des(;ribed  by  Hughes  in  cais- 
son disease,  Tlie  pain  may  extend  along  the  sole  of  the  foot  or  be  confined  to 
the  tips  of  the  toes,  occasionally  fo  the  ball  of  the  great  toe.  Nund)ness, 
tingling,  hvperaesthesia,  and  sweating  may  occur  with  it.  A  cm-ions  tender- 
ness of  the  toes,  possibly  due  to  a  ixniitis,  is  n<it  infrc(|iicntly  seen  in  typhoid 
fever  in  patients  who  have  been  sul)jecte<l  to  llie  cold-hath  treatment. 


848  disease:^  of  the  nerves. 

In  this  connection  may  be  mentioned,  as  possibly  due  to  a  neuritis  of  the 

nerves,  the  condition  described  by  Weir  Mitchell  as  erythromelalgia,  which  is 

accompanied  with  great  pain  in  the  heel  or  in  the  sole  of  the  foot,  and  vascular 

change,  either  an  acute  hypenemia  or  cyanosis.     It  is  an  affection  similar  in 

•most  respects  to  Raynaud's  disease. 

Sciatica. 

This  is  either  a  neuritis  of  the  sciatic  nerve  or  of  its  cords  of  origin.  It  is 
regarded  sometimes  as  a  functional  neurosis.  It  occurs  most  frequently  in 
adult  males.  Rheumatism  or  gout  is  present  in  many  cases.  Exposure  to- 
cold,  particularly  after  heavy  muscHlar  exertion,  or  a  severe  wetting  is  not  an 
uncommon  cause.  The  nerve-cords  of  the  sacral  plexus  may  be  compressed 
by  ovarian  or  uterine  tumors,  by  lymphadenomata,  or  by  the  foetal  head  dur- 
ing labor.  Occasionally  lesions  of  the  hip-joint  induce  a  secondary  sciatica. 
The  condition  of  the  nerve  has  been  examined  in  a  few  cases.  In  the  opera- 
tion of  stretching  it  has  been  found  swollen  and  reddened.  Histologically,  an 
interstitial  neuritis  has  been  present.  The  affection  may  be  most  intense  at  the 
sciatic  notch  or  in  the  nerve  about  the  middle  of  the  thigh. 

Of  the  symptoms,  the  most  constant  and  troublesome  is  pain,  which,  as  a 
rule,  sets  in  gradually,  and  for  a  time  may  be  slight  and  confined  to  the  back 
of  the  thigh,  and  felt  particularly  in  certain  })ositions  or  after  exertion.  At 
the  onset  there  may  be  fever.  Soon  the  pain  becomes  more  intense,  and, 
instead  of  being  limited  to  the  upper  portion  of  the  nerve,  extends  down  the 
thigh,  reaching  the  foot  and  radiating  over  the  entire  distribution  of  the  nerve. 
The  patient  can  often  point  out  the  most  sensitive  spots,  usually  at  the  notch 
or  in  the  middle  of  the  thigh,  and  on  pressure  these  are  exquisitely  painful. 
The  ]iain  is  described  as  gnawing  or  burning,  and  is  usually  constant,  but  in 
some  instances  is  paroxysmal,  and  often  worse  at  night.  On  walking  the  knee 
is  bent  and  the  patient  treads  on  his  toes,  so  as  to  relieve  the  tension  on  the 
nerve.  In  protracted  cases  there  is  wasting  of  the  muscles,  but  the  reaction  of 
degeneration  can  seldom  be  obtained.  In  these  chronic  cases  cramps  may  occur 
and  fibrillary  contractions.  Herpes  may  develop,  but  this  is  unusual.  In 
rare  instances  the  neuritis  ascends  and  involves  the  spinal  cord. 

The  duration  and  course  are  extremely  variable.  As  a  rule,  it  is  an 
obstinate  affection,  lasting  for  months,  or  even,  with  remissions,  for  years. 
Relapses  are  not  uncommon,  and  the  disease  may  be  relieved  in  one  nerve 
only  to  appear  in  the  other.  In  the  severer  forms  the  patient  is  bed-ridden, 
and  such  cases  prove  among  the  most  distressing  and  trying  which  the  physician 
is  called  upon  to  treat. 

In  the  diagnosis  it  is  important,  in  the  first  ]ilace,  to  d.etermine  whether 
the  disease  is  primary,  or  secondary  to  some  affection  of  the  pelvis  or  of  the 
spinal  cord.  A  careful  rectal  examination  should  be  made,  and  in  women 
pelvic  tumor  should  be  excluded.  Lumbago  may  be  confounded  with  it. 
Affections  of  the  hip-joint  are  easily  distinguished  by  the  absence  of  tender- 
ness in  the  course  of  the  nerve  and  the  sense  of  pain  on  movement  of  the  hip- 


SCIATICA.  849 

joint  or  on  pressure  in  the  region  of  tlie  trochanter.  There  are  instances  of 
sacro-iliac  disease  in  which  the  patient  comphiins  of  pain  in  tlie  upper  part  of 
the  thigh,  which  may  sometimes  radiate,  but  careful  examination  will  readily 
distinguish  between  the  atfections.  Pressure  on  the  nerve-trunks  of  the  cauda 
equina,  as  a  rule,  causes  bilateral  pain  and  disttn-bances  of  sensation,  and,  as 
double  sciatica  is  rare,  these  features  always  suggest  lesion  of  the  nerve-roots. 
Between  the  severe  lightning  pains  of  tabes  and  sciatica  the  differences  are 
usually  well  defined. 

Treatment.— The  pelvic  organs  should  be  carefullv  and  svstematicallv 
examined.  Constitutional  conditions,  such  as  rheumatism  and  gout,  should 
receive  appropriate  treatment.  In  a  few  cases  with  pronounced  rheumatic 
history,  wherein  the  trouble  comes  on  acutely  with  fever,  the  salicvlates  seem 
to  do  good.  In  other  instances  they  arc  quite  useless.  If  there  be  a  sus- 
picion of  syphilis,  the  iodide  of  potassium  should  be  employed,  and  in  gouty 
cases  salines. 

Rest  in  bed  with  fixation  of  the  lind)  by  means  of  a  long  splint  is  a  most 
valuable  method  of  treatment  in  many  cases,  one  upon  which  Weir  Mitchell 
has  specially  insisted.  I  have  known  it  to  relieve,  and  in  some  instances  to 
cure,  obstinate  and  protracted  cases  which  had  resisted  all  other  treatment. 
Hydrotherapy  is  sometimes  satisfactory,  particularly  the  warm  baths  or  the 
mud  baths.  Many  cases  are  relieved  by  a  prolonged  residence  at  one  of  the 
thermal  springs.     Antipyrine,  antifebrin,  and  quinine  are  of  doubtful  benefit. 

liocal  applications  are  more  beneficial.  The  hot  iron  or  the  thermo-cautery 
or  blisters  relieve  the  pain  temporarily.  Deep  injections  into  the  nerves  give 
great  relief,  and  may  be  necessary  for  the  ])ain.  It  is  best  to  use  cocaine  at 
first,  in  doses  of  an  eighth  to  a  quarter  of  a  grain.  If  the  pain  is  unbearable, 
morphine  may  be  used,  but  it  is  a  dangerous  remedy  in  sciatica  and  should  be 
withheld  as  long  as  possible.  The  disease  is  so  protracted,  so  liable  to  relaj>se, 
and  the  patient's  morale  so  undermined  by  the  constant  worry  and  the  sleepless 
nights,  that  the  danger  of  contracting  the  morphine  habit  is  very  great.  On 
no  consideration  siiould  the  patient  l)e  permitte<l  to  use  the  hypodermic  needle 
himself.  It  is  remarkable  how  promptly,  in  some  cases,  the  injection  of  dis- 
tilled water  into  the  nerve  will  relieve  the  pain.  Acupuncture  may  also  be 
tried  :  the  needles  should  Ix'  thrust  deeply  into  the  luost  painful  spot  for  a 
distance  of  about  two  inches,  and  left  for  from  lil'ti'di  to  twculy  minutes. 
The  injection  of  chloroform   int<»  the  ucrvc  has  also  bccii   recommended. 

Electricity  is  an  uncertain  remedy.  Sometimes  it  gives  ))rom|)t  relief;  in 
<jther  cases  it  mav  be  used  for  weeks  without  the  slightest  benefit.  It  is  mo.st 
serviceable  in  the  chronic  cases  iu  whieh  there  is  wasting  of  the  legs,  and 
should  be  combined  with  massage.  The  galvanic  <urreiit  sliMiild  be  used;  a 
flat  electrode  should  be  phn-ed  ovei-  the  sciatic  iioteli,  and  a  smaller  (me  use<l 
alono"  the  course  of  the  nerve  and  its  branches.  In  verv  obstinnte  cases  nerve- 
stretchinsx  mav  be  emploved.  It  is  sometimes  sueeessfid,  i»nt  in  dllier  instances 
the  condition  recurs  and  is  as  bad  as  ever. 

Vol.  I. — 5-t 


DISEASES  OF  THE  MUSCLES. 

By  WILLIAM  OSLER. 


MYOSITIS. 


Primary  myositis  is  an  aflFection  of  which  sev^eral  well-characterized  cases 
have  been  recorded  within  the  past  few  years.  In  Jacobi's  patient  swelling 
and  pain,  with  loss  of  power,  began  in  the  mnscles  of  the  lower  extremi- 
ties and  gradually  involved  the  other  muscles  of  the  body,  which  became 
firm,  hard,  and  tender.  Finally,  atrophy  supervened  in  certain  groups. 
Death  occurred  in  about  two  years  and  a  half  from  involvement  of  the 
respiratory  muscles.  The  condition  found  was  a  myositis  and  perimyositis. 
The  cases  may  progress  more  rapidly  :  thus  in  E.  Wagner's  case  the  patient, 
a  tuberculous  woman,  complained  of  stiffness  about  the  shoulders  and  oedema 
of  the  back  of  the  hand  and  forearm,  with  parsesthesia.  The  muscles  felt 
doughy  and  were  painful  on  pressure.  The  legs  gradually  became  involved, 
and  death  occurred  in  about  three  months.  The  muscles,  with  the  exception 
of  the  glutei,  calf,  and  abdominal  muscles,  were  stiff,  firm,  and  fragile,  and 
showed  fatty  degeneration  and  great  proliferation  of  the  interstitial  tissue. 
In  Hepp's  case  there  was  hyaline  degeneration  of  variable  grades  of  the 
muscle-fibres  and  the  intermuscular  tissue  was  scarcely  involved.  In  the  case 
of  Unverricht  the  interstitial  tissue  was  much  infiltrated  and  the  muscle-fibres- 
greatly  degenerated.  In  both  of  these  cases  the  spleen  was  enlarged.  Ac- 
cording to  Lowenfeld,  the  disease  is  characterized  by  three  cardinal  symptoms: 
(1)  swelling  of  the  extremities,  due  in  part  to  the  oedema  of  the  subcutaneous 
tissues,  and  in  part  to  increase  in  the  volume  of  the  muscles,  with  which  is 
associated  a  corresponding  disturbance  of  function  ;  (2)  extension  of  the  inflam- 
matory affection  to  the  muscles  of  respiration  and  deglutition  ;  and  (3)  the 
presence  of  a  more  or  less  extended  exanthem. 

The  exanthem  in  the  majority  of  the  cases  has  been  of  an  erythematous 
nature  and  irregularly  scattered  over  the  trunk  and  extremities,  and  has  some- 
times been  followed  by  slight  pigmentation.  Disorders  of  sensation  are  not 
usually  present. 

The  swelling  of  the  muscles,  the  soreness  and  oedema,  and  the  pain  nat- 
urally suggest  trichinosis.  The  diagnosis  could  only  be  made  in  some  instances 
by  examination  of  portions  of  the  muscle  excised.  Wagner  suggests  that  some 
of  the  cases  are  examples  of  acute  progressive  muscular  atrophy. 

Acute  purulent  myositis  is  not  very  infrequent  in  pyaemia.     It  is  occasion- 

850 


IDIOPATHIC  MUSCULAR    ATROPHY.  851 

ally  one  of  the  sequelae  of  typhoid  fever.     There  are  instances  on  record  in 
which  it  apparently  has  been  the  primary  atJection, 

Myositis  ossificans  proc/ressiva  is  a  rare  disease  in  which  the  muscles  under- 
go a  ])rogressive  calcification.  In  this  remarkable  disorder  either  in  local izetl 
spots  or  in  widespread  areas  the  muscle-tissue  untlergoes  gradual  ossification. 
Of  22  cases  collected  by  Seidel,  a  majority  were  in  men,  and  in  more  than 
one-half  of  the  cases  the  disease  began  before  puberty.  The  onset  is  usually 
with  indications  of  an  inflammatory  process  in  the  muscle,  sometimes  with 
swelling  and  tenderness.  This  gradually  subsides,  and  the  nuisclc  becomes 
firm,  hard  like  gutta-percha,  and  gradually  undergoes  conversion  into  bony 
tissue.  The  process  may  be  confined  to  one  or  two  muscles  or  to  certain 
groups.  In  other  instances  the  process  is  widespread  and  involves  many 
muscles  of  the  trunk  and  extremities.  In  Rogers's  case,  for  example,  the  first 
reported  in  this  countiy,  the  disease  began  at  thirteen  years  of  age.  At  the 
time  of  observation  "  it  was  found  that  the  pectoralis  major  muscle  was  ossi- 
fied at  its  superior  part  and  extended  in  the  direction  of  the  clavicle  to  the 
arm,  the  bony  deposits  forming  high  and  irregular  elevations.  The  sterno- 
cleido-mastoideus  was  ossified  from  the  sternum  to  its  micUlle  portion,  with 
several  elevations.  The  back  exhibited  tlie  greatest  quantity  of  ossific  mat- 
ter, having  a  tubercular  appearance.  The  scapula  was  fixed  to  tiie  ribs  and 
studded  with  bony  excrescences.  All  the  nuiscles  going  to  the  scapula  ap- 
peared more  or  less  affected — viz.  the  trapezius,  rhomboideus,  subsca])ularis, 
etc.  The  latissimus  dorsi  formed  a  large  bony  plate  from  its  origin  to  the 
angle  of  the  scapula  ;  at  this  part  it  had  united  to  the  ribs,  forming  a  large 
tubercle.  The  longissimus  dorsi  was  in  a  similar  condition,  extending  upward 
along  the  spine,  resembling  a  splint,  and  to  this  may  be  attributed  the  entire 
loss  of  motion  in  the  lumbar  vertei)ra." 

The  disease  lasts  many  years,  and   may  ultimately   lead  to  complete  dis- 
ability.    No  remedial  measures  have  proved  of  any  avail. 


THE  MUSCULAR  DYSTROPHIES. 

iDIOPATIIir    MUSCFLAR    AtI.'OI'IIV. 

The  following  classification,  taken   fiom    Raymond's   monograj)!!,  gives  a 
usefid  synopsis  of  the  varieties  and   causes  uf  niusciilar  atro|)hy  : 


Circumscribed  atrophic: 


Atro|»li\'  iVuiii  (•(iiiiprcssiou. 

Atropliv  in  iiillainmatory  conditions  (pleurisy,  joint 

disease,  etc). 
Atropliv  iVom  injury  or  inllammation  of  individual 

nerves. 


852 


DISEASES    OF    THE  MUSCLES. 


Progressive  atrophies 


Diffuse  atrophies 


^  Progressive  spinal  muscular  atrophy  ;  type  Aran- 
Duchenne. 

Pseudo-hypertrophic  muscular 

paralysis. 
Type  Leyden-Mobius. 
Type  Zim merlin. 
Type  Erb. 

Type  Landouzy-Dejerine. 
Type  Gharcot-Marie. 


Progressive  myo- 
pathic atrophy 


Anterior      polio- 
myelitis .  .  .  . 


Facial  hemiatrophy 


Muscular  atrophy  of  cer- 
ebral origin 


''  Infantile  form. 
Acute  of  adults  ;  spinal  paral- 
ysis, with  rapid  course  and 
curable  (Landouzy  -  Deje- 
rine) ;  subacute  and  chronic 
form  ;  chronic  mixed  form 
(Erb) ;  diffuse  subacute,  gen- 
eral spinal  paralysis  (Du- 
chenne). 
Syringomyelia. 

Multiple  neuritis 
(amyotrophic 
form). 

C  With   secondary  degeneration    involving  the  an- 
terior cornua. 
Without  secondary  degeneration  involving  the  an- 
terior cornua. 


Lead  paralysis. 
Leprous  neuritis. 
Alcoholic  neuritis. 


I 


Muscular  atrophy  in  hysteria 
Muscular   atrophy  from 
systemic  disease  of  the 
cord 


Amyotrophic  lateral  sclerosis. 
Glosso-labio-laryngeal  paralysis. 


Atrophy  complicating 
other  disease  of  the 
cord 


Atrophy  in  myelitis. 
Atrophy  in  compression  of  the  cord. 
Atrophy  in  multiple  sclerosis. 
Atrophy  in  tabes  dorsalis. 


We  shall  here  consider  only  the  idiopathic  muscular  atrophy,  the  primary 
muscular  dystrophy  of  Erb.  The  disease  is  ciuiracterized  by  muscular  wast- 
ing with  or  without  an  initial  hypertrophy.  The  essential  change  is  in  the 
muscles  themselves,  and  as  hereditary  influences  play  an  imjwrtant  role,  it  is 
probable  that  there  is  some  inherent  defect  in  the  germinal  tissues  from  which ^ 
the  muscular  system  is  developed. 

Etiology. — Congenital  tendencies  exist  in  many  instances,  and  the  disease 
is  met  with  in  family  groups  or  many  members  are  attacked  through  several 


IDIOPATHIC  MUSCULAR   ATROPHY 


853 


generations.  As  other  family  affections,  the  disease  mav  be  transmitted  bv  a 
mother  in  whose  family  the  disease  exists,  but  who  is  herself  exempt.  As  a 
rule,  the  disease  appears  during  the  stage  of  development,  sometimes  very 
early,  just  as  the  child  is  beginning  to  walk.  In  other  instances  the  first 
symptoms  may  appear  after  adolescence.  Other  than  hereditary  no  etiological 
factors  are  known. 

Clinical  Forms. — («)  Pseudo-hi/pertrophic  Ti/pc. — The  pseudo-hypertrophic 
muscular  })aralysis  is  a  well-characterized  and  readilv  recognized  affection,  on 
account  of  the  increase  in  size  of  certain  of  the  muscle-groups.  The  child  is 
first  noticed  to  be  clumsy  in  its  movements,  to  fidl  easily,  and  to  stumble  in 
going  up  stairs.  Nothing  may  at  first  be  noticeable,  but  soon  the  attention  is 
attracted  to  enlargement, of  certain  of  the  muscles,  particularly  of  the  calves  of 
the  legs,  which  may  stand  out  with  extraordinary  prominence.   (See  Fig.  58.) 


Fig.  58. 


Pseudo-hypertrophic  Muscular  Paralysis. 

The  extensors  of  the  leg,  the  gluti-i,  tlie  lumljar  muscles,  the  deltoids,  the  triceps, 
and  infrasj)inati,  arc  the  next  mcjst  frequently  involved.  'J'lie  last-named  may 
stand  out  with  great  prominence.  The  nuisdes  of  the  face,  neck,  and  forearm 
arc  rarely  involved,  and  in  marked  contrast  to  the  spinal  forms  of  primary  mus- 
cular atrophy  the  intrinsic  muscles  of  the  linnd,  in  this  as  in  (itlicr  \:ii'ieties  of 
muscular  atroj)hy,  are  spared.  With  tlic  hy|Mitr(i|)liy  of  ccrlaiu  nuiscies  or  of 
groups  of  iiuisclcs  there  is  wasting  of  others,  and  there  may  be,  for  example, 
great  enlargement  of  the  calves,  with  wasting  ;iiiil  weakness  of  the  extensors 


854 


DISEASES    OF    THE   MUSCLES. 


of  the  legs  and  of  the  muscles  of  the  shoulder-girdle  and  of  the  back.  In 
moderately  advanced  cases  the  attitude  when  standing  is  characteristic.  The 
legs  are  far  apart,  the  shoulders  thrown  back,  the  spine  curved,  and  the  abdo- 
men protuberant.  Owing  to  the  loss  of  power  in  the  extensors  of  the  hip,  the 
gait  has  a  remarkable  waddling,  oscillating  character,  "  in  which  the  body  is  so 
inclined  as  to  bring  the  centre  of  gravity  over  each  foot,  on  which  the  patient 
successively  throws  his  weight,  because  the  weak  gluteus  medius  cannot  coun- 
teract the  inclination  toward  the  leg  that  is  off  the  ground  unless  the  balance 
is  exact"  (Gowers).  In  getting  up  from  the  floor  the  various  positions  assumed 
are  quite  ])athognomonic,  and  have  been  rendered  very  familiar  by  the  frequent 
reproduction  of  Gowers's  well-known  figures.  The  child  turns  over  in  the 
all-fours  position,  raises  the  trunk  with  the  arms,  gradually  moves  the  hands 
along  the  ground  until  the  knees  are  reached  ;  then  with  one  hand  upon  a 
knee  he  lifts  himself  up  and  grasps  the  other  knee,  and  gradually  pushes 
himself  into  the  erect  posture,  climbing  up  his  legs,  as  it  is  said. 

The  course  of  the  disease  is  slow  and  progressive.  The  pseudo-hyper- 
trophic  muscles  gradually  waste.  The  greatest  weakness,  however,  may  be  in 
muscle-groups  which  have  not  been  primarily  enlarged.  At  a  late  period  con- 
tractures, lateral  curvature,  and  various  forms  of  talipes  are  present. 

(6)  Primary  Atrophic  Form. — A  number  of  types  of  muscular  atrophy 
have  been  described,  chiefly  according  to  the  muscle-groups  which  they 
involve,  all  of  which  are  merely  varieties  of  one  and  the  same  affection,  and 
differ  only  in  their  characters  from  the  pseudo-hypertrophic  type  in  an  absence 
of  the  primary  enlargement.  They  are  all  connected  by  intermediate  forms 
with  each  other,  and  all  occur  in  family  groups.  As  a  rule,  the  type  which 
prevails  in  a  family  is  the  same  in  the  different  members  affected,  but  occasion- 
ally in  one  family  examples  are  met  with  of  the  pseudo-hypertrophic  and  the 
simple  atrophic  types.  The  following  are  tiie  important  types  of  the  simple 
atrophic  form  : 

Juvenile  Form  of  Erb. — In  tliis  the  affection  begins  as  a  rule  about 
puberty,  and  involves  the  muscles  of  the  upper  arm  and  shoulder  and  of 
the  gluteal  and  thigh  groujjs.  The  deltoid  is  often  spared.  The  calf  muscles 
may  be  enlarged  and  hard.  Later  the  back  muscles  are  involved,  and  the 
patient  assumes  on  standing  the  characteristic  attitude  mentioned  in  tlie 
pseudo-hypertrophic  form.  There  are  no  special  electrical  changes,  and  even 
when  the  wasting  is  extreme  the  reaction  of  degeneration  is  not  present. 
Several  children  in  the  same  family  may  be  attacked,  and,  as  in  other  forms, 
the  disease  is  witli  occasional  interruptions  progressive  and  leads  to  complete 
disability. 

Infantile  type  of  Duchenne,  the  facio-scapido-humeral  form  of  Landouzy 
and  Dejerine,  in  which  the  disease  sets  in  as  a  rule  in  childhood,  but  may  be 
delayed  until  after  the  twentieth  year.  It  is  characterized  by  involvement  of 
the  facial  muscles,  so  that  the  lower  face  and  forehead  are  expressionless,  and 
move  slowly  in  laughing.  The  lips  are  often  protuberant,  thick,  and  everted, 
and  cannot  be  pursed  as  in  the  act  of  whistling.     The  eyes  cannot  be  com- 


IDIOPATIIJC   MUScri.AR    ATROPHY.  855 

pletely  closed.  The  miisole.s  of  the  shoulder-ijirclle  waste  aiul  the  hirger 
muscles  of  the  thighs.  Erb  calls  attention  to  the  valuable  test  of  the 
strength  of  the  siioukler-girtlie  muscles  in  lifting  the  child  bv  the  arm-])its, 
when  in  weakness  of  these  groups  no  resistance  is  oifered  and  the  shoulders 
are  forced  up  almost  to  the  child's  ears. 

Intermediate  forms  and  types  are  met  with,  but  do  not,  however,  need 
special  description. 

In  all  fornis  the  onset  of  the  disease  is  gradual,  and  the  wasting  and  weak- 
ness produced  simultaneously  in  the  various  muscle-groups  already  men- 
tioned. A  striking  feature  is  the  absence  of  wasting  in  the  intrinsic  nuiseles 
of  the  hands — a  contrast  to  the  s])inal  form  of  muscular  atrophy.  'Hie 
muscles  of  the  tongue,  pharynx,  larynx,  and  eye  are  not  att'ccted.  lu  all 
varieties  the  electrical  irritability  of  the  muscles  is  lessened  in  direct  propor- 
tion to  the  wastiuir.  There  is  no  reaction  of  deo;eneration.  Fibrillarv  twitch- 
ing  is  rarely  present.  The  sensation  is  unimpaired.  The  reflexes  are  weak  ; 
in  the  later  stages  lost,  never  increased.  The  sphincters  are  not  involved. 
Late  in  the  disease  deformities  occur,  such  as  cin-vature  of  the  spine  and 
various  forms  of  talipes. 

The  disease  persists  for  an  indefinite  period,  and  it  may  be  many  years 
before  the  patient  is  bed-ridden. 

Morbid  Anatomy. — The  spinal  cord  and  peripheral  nerves  have  been 
found  normal,  but  Erb  thinks  that  there  are  certain  features  which  ]K)int  to 
central  dynamic  changes  as  the  cause  of  the  atrophy,  such  as  heredity,  the 
special  localization,  and  the  existence  occasionally  of  associated  disorders  of  the 
brain,  such  as  idiocy  and  0})i]e]>sy.  In  the  j)seudo-hy])ertrophic  form  the 
muscle-fibres  present  great  variations  in  size.  In  the  early  stage  there  may  be 
marked  enlaro-ement  and  the  nuclei  of  the  sarcolemma  are  increased.  The 
fibres  have  sometimes  been  seen  to  be  fissured  longitudinally.  The  enlarge- 
ment is  chiefly  due  to  the  increase  in  the  connective  tissue  and  f:it,  liy  which 
in  the  later  stages  the  muscle  may  be  largely  re])laced.  In  the  j)riniary 
atrophic  form  a  similar  enlargement  of  the  muscle-fibres  has  been  noticed. 
The  increase  in  the  interstitial  tissue  is  not  so  striking.  The  wasting  ni"  the 
fibres  and  the  replacement  by  connective  tissue  and  i'at  seem  to  be  gradual 
processes. 

Diagnosis. — The  pseudo-hypertrophic  form  is  recognizable  at  a  glance. 
The  striking  contrast  between  the  athletic  a|)p<'araiii'e  and  the  lecble  condition, 
the  attitude,  gait,  and  mofle  of  rising  from  the  floor,  make  up  an  unmistakable 
symptom-grouj).  It  is  to  be  rememlxM'ed,  howcvei-,  (hat  th<>  gait  and  the 
mode  of  rising  may  be  (piite  as  characteristic  of  the  simple  atrophic  forms. 
The  occurrence  in  finnily  groups  is  also  a  point  of  great  importance.  From 
myelopathic  or  spinal  muscular  atrophy  the  forms  are  usually  easily  scj)arated. 
In  the  atrophv  of  chroni<!  p(Jioiuyclitis  anteiior  the  small  muscles  of  the  hand 
are,  as  a  nde,  first  attacked,  whereas  in  the  |.iiiii;iry  Miyo|)atliics  the  imisclcs  of 
the  calves  or  of  the  shoulder-girdle  or  of  the  thighs  are  first  involved,  in 
spinal   atrophy   the  reacti(Mi  of  degeneration   i-^   pn'-ent   and   fibrillary  twitch- 


856  DISEASES    OF    THE   MUSCLES. 

ings  are  more  constantly  met  with.  In  addition  to  the  wasting  there  is  not 
infrequently  increase  in  the  reflexes  and  a  spastic  condition  of  the  legs.  The 
myelopathic  atrophies  come  on  late  in  life ;  the  myopathic,  as  a  rnle,  in  child- 
hood or  adolescence.  Heredity  plays  an  important  role  in  the  primary  mus- 
cular atrophies. 

The  Peroneal  Type  of  3Iuscular  Atropliy. — This  form,  Avhich  has  been 
described  by  Charcot  and  Tooth,  was  at  first  regarded  as  a  myopathy,  but 
presents  differences  which  make  it  doubtful  whetlier  it  should  come  into  this 
category.  The  wasting  begins  in  the  muscles  of  the  legs,  usually  in  the 
extensors  of  the  great  toe,  afterward  in  the  common  extensors  and  in  the 
peronei  muscles.  The  small  muscles  of  the  foot  may  be  early  affected. 
Later  the  thigh  muscles  are  involved.  The  unequal  involvement  of  the  legs 
in  early  childhood  very  commonly  results  in  club-foot.  The  disease  progresses 
slowly,  and  it  may  be  years  before  the  muscles  of  the  upper  extremities  are 
involved.  Here  the  order  of  attack  is  quite  unlike  the  myopathic  form,  as  the 
the  thenar  and  hypothenar  and  interossei  are  first  involved,  often  symmetri- 
cally, producing  in  some  cases  the  claw-hand.  Fibrillary  contractions  and  the 
reaction  of  degeneration  may  be  present.  Sensory  disturbances  have  also  been 
noted,  particularly  impairment  of  tactile  sensation,  })ains,  more  rarely  vaso- 
motor changes. 

The  essential  nature  of  this  form  is  still  in  doubt,  but  it  may  possibly  be 
a  neuritic  disorder.  Males  are  attacked  much  more  frequently  than  females. 
Heredity  has  been  present  in  many  cases,  usually  through  the  mother. 

The  outlook  in  the  primary  myopathies  is  unsatisfactory,  and  it  does  not 
appear  probable  that  any  drug  or  form  of  treatment  influences  in  the  slightest 
degree  the  slow  but  progressive  course  of  the  disease.  The  general  health 
should  be  attended  to,  moderate  exercise  allowed,  and  the  muscles  may  be 
stimulated  by  massage  and  electricity.  When  the  patient  becomes  bedfast 
care  should  be  taken  to  prevent  contractures  in  awk\vard  positions. 

Thomsen's  Disease  (Myotonia  Congenita). 

Definition. — An  hereditary  affection  characterized  by  tonic  cramps  in  the 
muscles  on  attempting  to  perform  voluntary  movements.  The  disease  has 
received  its  name  from  the  physician  who  first  described  it,  in  whose  family  it 
has  been  hereditary  for  several  generations. 

Etiology. — The  disease  appears  to  be  most  coiumon  in  Scandinavia  and  in 
Germany.  A  majority  of  the  cases  have  occurred  in  family  groups.  The 
sexes  are  equally  involved. 

Symptoms. — The  disease  sets  in  early,  and  it  is  noticed  that  on  account 
of  stiffness  of  the  movements  the  child  is  una])le  to  take  part  freely  in  games.- 
In  some  instances  the  peculiar  symptoms  are  not  noticed  until  after  puberty. 
The  characteristic  feature  of  the  disease  is  only  noticed  in  the  performance  of 
a  voluntary  movement.  The  muscles  become  rigid  and  fixed  on  attempting 
to  move,  or  the  contraction  which  the  patient  wills  is  very  slowly  accomplished 
and  the  relaxation  is  also  slow.     In  walking  the  start  is  difficult:  one  leg 


THOMSEy\S   niSKA si:.— PA  R.  I  ^rYO<  L OXl  S   M L  L  TJPLEX.    857 

is  put  forward  slowly,  and  I'or  {KTliaps  a  second  or  two  is  stiff  and  can  scarcely 
be  moved.  Gradually  this  rigidity  wears  off,  the  logs  become  limber,  and  the 
patient  can  walk  for  hours  without  fatigue.  After  a  period  of  rest  the  same 
initial  difficulty  is  experienced.  The  muscles  of  the  arms  and  legs  are  those 
implicated.  Motion  and  cold  aggravate  the  condition.  Sensation  and  the 
reflexes  are  normal.  In  some  instances  there  have  been  mental  changes,  such 
as  hypochondria.  The  patients  are  well  nourished  and  appear  nuiscular.  In 
some  instances  there  has  been  great  increase  in  the  nniscular  strength  ;  in 
others  the  strength  is  scarcely  in  proportion  to  the  size  of  the  muscles.  The 
muscles  are  very  sensitive  to  mechanical  stimuli,  and  pressure  u)>i»n  them  may 
be  followed  bv  a  tonic  contraction  lasting  manv  seconds.  Erb  has  described 
a  characteristic  reaction  of  the  nerve  and  muscle  to  the  electrical  currents,  the 
so-called  myotonic  reaction,  the  chief  feature  of  which  is  that  the  contractions 
caused  by  either  current  attain  their  maximum  slowly  and  relax  slowly,  and 
that  vermicular  wave-like  contractions  pass  from  the  catiiode  to  the  anode. 
The  condition  persists  throughout  life.  In  a  few  instances  it  has  been  arrested 
temporarily,  and  there  have  been  changes  and  variations  in  the  intensity  of  the 
manifestations. 

No  post-mortem  has  yet  been  made  upon  the  disease.  INIany  examinations 
have  been  made  of  excised  portions  of  muscle,  and  in  all  instances  the  fibres 
have  been  found  to  be  greatly  increased  in  size,  and  in  some  instances  accom- 
panied with  an  increase  in  the  nuclei  of  the  sarcolemma  and  of  the  interstitial 
tissue.  The  true  nature  of  the  disease  is  unknown,  but  it  is  usually  placed 
amou":  affections  of  the  muscles. 

No  treatment  for  the  disease  has  yet  been  found. 

Affections  which  may  be  regarded  as  varieties  of  Thomsen's  disease  are  on 
record ;  thus,  Eulenberg  reported  a  series  of  cases,  the  history  of  which  could 
be  traced  through  six  generations,  in  which  there  were  tonic  spasms  of  variable 
duration,  affecting  chiefly  the  muscles  of  the  face  and  less  often  those  of  the 
extremities.  The  contractions  are  followed  by  weakness.  As  it  aj>peared  in 
some  mendicrs  of  the  family  shortly  after  birth,  he  termed  it  congenital  para- 
myotone.  In  other  instances,  as  in  a  case  described  by  Gowers,  the  tonic 
spasm  was  associated  with  distinct  ataxia. 

Paramyoclonus  Multiplex. 
This  is  an  affection   first  described  by  Friedivich,  characterized  by  clonic 
oontradion,  chiefly   of  the   nuisclcs  of  the  extremities,   occurring  usually  in 

paroxysms. 

A  majoritv  of  the  cases  have  been  in  male  adults.  The  disease  has  most 
frc(|nciitly  followed  fright  or  violent  emotion  or  an  injury.  'V\u'  clonic  spasms 
usually  begin  in  the  muscles  of  the  legs,  and  i.kiv  at  first  ik.I  be  severe  enough 
to  j)revcnt  the  patient  from  working,  and  tli.\-  .an  l)e  to  a  certain  ineasure 
controlled.  They  are,  as  a  rule,  l)ilat('ral,  and  vary  iVoni  lilly  to  a  hun<lred 
and  fiftv  in  a  minute.  In  tlie  iiii(iv;il-  between  the  attacks  there  may  be 
treraons  in  the  muscles.     Sometimes  the  (•..ntniciions  are  defmitcly  rhythmical. 


858 


DISEASES    OF    THE   MUSCLES. 


In  the  severer  attacks  the  spasms  involve  the  muscles  of  the  back  and  of  the 
abdomen,  and  may  become  very  violent,  so  that  it  is  difficult  to  keep  the 
patient  in  bed. 

The  course  of  the  disease  is  variable.  The  spasms  may  recur  at  intervals 
for  years,  and  in  a  majority  of  the  cases  recovery  ultimately  takes  place.  It 
may  only  be  a  manifestation  of  hysteria.  Many  of  the  cases  have  yielded 
promptly  to  powerful  electrical  currents. 


f. 


VASOMOTOR  AND  TROPHIC  DISORDERS. 

Bv  willia:m  oslkr. 


Raynaud's  Disease. 

Definition. — A  vascular  disorder  characterized  by  three  stages,  or,  more 
properly,  three  grades  of  intensity  :  local  syncope,  local  asphyxia,  and  local 
or  symmetrical  gangrene.  The  nature  of  the  disease  is  still  obscure,  but  it  is, 
in  all  probability,  a  vaso-motor  neurosis.  Raynaud's  original  papers  and  an 
exhaustive  summary  of  the  literature  \vill  be  found  in  I5arlow's  translation  for 
the  New  Sydenham  Society. 

Local  SY^xoPE. — This  is  the  most  common  manifestation,  and  produces 
in  the  extremities  a  condition  projierly  known  as  dead  fingers  and  dead  toes. 
It  is  most  frequently  met  with  in  women  of  a  nervous  temperament.  The 
condition  is  present  usually  only  in  cold  weather,  and  follows  sligiit  exposure. 
Occasionally  an  emotion  causes  it,  as  fright  or  an  hysterical  outbreak.  Both 
hands  may  be  affected,  or  one  hand  alone,  or  one  or  two  fingers,  sometimes  the 
nose  and  the  ear.  The  affected  parts  become  cold,  bloodless,  and  of  an 
"alabaster  whiteness.  The  fingers  and  hand  are  stiff  and  move  with  dilfi- 
culty,  but  are  rarely  ])ainful  except  when  the  syncope  is  jiassing  off.  After 
jM'rsisting  for  a  variable  time  the  pallor  gradually  disapjiears,  and  the  affected 
parts  become  either  of  a  normal  color,  or  the  blood-vessels  relax  and  there  is  a 
condition  of  great  engorgement  or  local  asphyxia.  The  two  ])henomena  niav 
be  present  in  adjacent  fingers,  r)ne  being  as  white  and  as  cold  as  marble,  the 
other  of  a  deej)  plum  color.  Local  syncope  is  not  often  serious,  and  may 
recur  for  years  during  the  winter  season. 

Local  Asphyxia. — This  may  come  on  indcixiiiicntly  (tr  folhtw  local 
syncope.  The  fingers  and  toes  are  most  often  iiiNdlved,  tlicn  the  cars  and 
nose,  and  less  often  ])ortions  of  the  skin  on  (he  arms,  legs,  and  tninU.  The 
affected  region  becomes  livid,  deeply  cyanosed.  and  the  fingers  and  to(s  may 
be  blue,  cold,  and  on  j)rcssure  the  capillary  circuladon  is  almost  al)sent,  the 
white  mark  made  by  pressure  of  the  finger  disappearing  very  slowly.  On  the 
limbs  and  trunk  the  disease  appears  in  livid  or  mottled  patches,  ."-li^hily 
raised,  and  sometimes  surrounded  by  a  /one  of  (edema  or  of  liyperaMnie  skin. 
The  hands  may  be  involved,  sometimes  the  li:ind>  and  feet,  and,  as  nieiilioned 
above,  some  of  the  fintrers  mav  be  in  the  condition  of  local  sNiicoite,  while 
others  are  deeply  cNanosed.  There  are  usually  swelling  and  some  jiain.  dne  to 
tension  of  the  parts.      Li  some  ca~es  there  is  marked  anav-tiiesia   and    niove- 

859 


860  VASO-MOTOB    AND    TROPHIC  DISORDERS. 

ment  is  much  impaired.  The  attacks  last  a  variable  time,  and  as  the  cyanosis 
passes  off  the  parts  become  of  a  bright-red  color,  in  which  the  circulation  is 
extremely  active.  In  adjacent  fingers  one  may  be  in  the  reaction  stage  of  a 
bright  scarlet  red,  and  the  anaemia  produced  by  pressure  is  instantaneously 
obliterated,  whereas  the  other  finger  may  be  of  a  deep  plum  color,  with  almost 
complete  stagnation  of  the  capillary  circulation.  When  the  local  asphyxia  is 
persistent  in  the  fingers  or  the  ear-tips,  there  may  be  slight  loss  of  substance, 
or  in  extreme  grades  the  condition  passes  on  into  local  gangrene.  The  attacks 
recur  at  irregular  intervals,  and  are  most  frequent  in  cold  weather.  Some 
patients  are  entirely  free  in  the  summer  months.  Sometimes  the  condition 
recurs  with  striking  ])eriodicity.  iVs  in  local  syncope,  the  disease  is  perhaps 
most  frequent  in  women.  Some  of  the  attacks  are  not  unlike  ordinary  chil- 
blains. The  condition  may  recur  for  years  without  leading  to  serious  trouble ; 
thus,  a  woman  of  about  thirty  has  had  in  the  winter  months  for  fourteen  or 
fifteen  years  almost  daily  some  grade  of  local  asphyxia  in  the  hands,  which  are 
sometimes  livid  and  cold  to  the  wrists.  The  fingers  show  only  slight  suj^er- 
ficial  losses  on  the  tips.  In  some  of  the  severer  attacks  mortification  of  the 
whole  hand  would  appear  to  be  almost  inevitable. 

Local  or  Symmetrical  Gangrene. — The  mildest  grade  of  this  con- 
dition is  seen  in  those  cases  of  local  asphyxia  in  which  small  necrotic  areas 
appear  on  the  tips  of  the  fingers  or  on  the  tips  of  the  ears.  Sometimes  the 
terminal  phalanges  are  quite  cicatricial  from  repeated  slight  losses  of  this  kind. 
In  severer  attacks  the  local  asphyxia,  which  may  be  either  primary  or  follow 
the  syncope,  persists.  If  in  the  extremities,  the  terminal  phalanges  become 
black,  cold,  and  insensible.  One  finger  only  may  be  affected,  or  several  fin- 
gers, or  the  entire  hand  or  foot.  More  or  less  pain  accompanies  this.  Instead 
of  disappearing  within  twenty-four  hours,  the  condition  persists,  and  small 
blebs  appear  on  the  skin,  which  may  be  quite  superficial.  Sometimes  without 
any  formation  of  bleljs  the  skin  becomes  dry  and  mummified.  A  line  of 
demarcation  is  gradually  formed,  and  a  portion  of  one  or  more  of  the  fingers 
sloughs  away.  In  very  severe  cases  the  gangrene  may  involve  several  fingers, 
or  the  ti])  of  the  nose  may  be  lost  or  a  portion  of  an  ear.  It  is  important  to 
note  that  the  loss  of  substance  is  very  much  less  than  the  apjiearance  of  the 
affected  limb  would  indicate.  The  gangrenous  blebs  may  be  quite  superficial 
and  result  in  only  necrosis  of  the  skin.  In  one  instance  in  which  the  feet  were 
completely  livid  and  superficial  blebs  appeared  on  the  instej)  and  the  toes  were 
livid  and  insensible,  instead  of  an  extensive  loss  of  substance,  as  had  been 
expected,  the  condition  cleared  and  there  were  only  superficial  abrasions. 
Pcrhajis  the  most  serious  cases  are  those  in  which  the  patches  of  gangrene 
affect  the  symmetrical  regions  in  different  parts  of  the  trunk  and  extremities. 
This  severe  type  is  most  apt  to  occur  in  children.  The  affected  regions  are  not 
necessarily  symmetrical.  Some  of  the  cases  have  been  preceded  or  accompanied 
with  purpura  of  the  skin  and  with  haemorrhages  from  the  mucous  surfaces.^ 

'  Musser,  "Grave  Forms  of  Purpura  Haemorrhagica,"  Transactions  of  the  Association  of  Amer- 
ican Physicians,  vol.  vi. 


HAYXAUD'.S   DISEASE.  86 1 

A  majority  of  these  cases  arc  fatal,  aiul  death  niav  f  )lhi\v  within  three  or  four 
davs. 

The  prognosis  as  regards  death  is,  as  a  rule,  good,  except  in  the  more 
malignant  lorms,  and,  as  already  mentioned,  the  destruction  of  tissue  is,  as  a 
rule,  very  much  less  than  the  appearance  of  the  affected  part  would  warrant. 
The  outlook  for  complete  recovery  is  not  very  hopeful. 

Associated  Conditions. —  There  are  very  remarkable  concomitant  .symp- 
toms in  Raynaud's  disea.se  to  which  of  late  nnich  attention  has  been  paid. 
Hjemoglobinuria  may  occur  during  an  attack  or  may  take  the  place  of  an  out- 
break. The  blood-coloring  matter  is  not  always  present.  There  may  be  only 
albuminuria.  In  a  case  which  has  been  at  my  clinic  on  several  occitsions  the 
local  asphyxia  with  slight  loss  of  substance  in  the  ears  recurred  for  three  suc- 
cessive winters,  alwavs  in  association  with  haemoglobinuria.  The  attacks 
were  usually  preceded  by  a  chill,  and  during  them  he  had  a  peculiar  sallow, 
subicteroid  hue.  The  relations  between  paroxysmal  hemoglobinuria  and  Ray- 
naud's disease  is  evidently  very  close,  and  some  have  regarded  them  as  man- 
ifestations of  one  and  the  .same  affection. 

Colicky  pains,  diarrluxja,  nausea,  and  vomiting  occasionally  occur  in  Ray- 
naud's di.sease,  but  are  not  so  common  as  in  intermittent  hemoglobinuria  and 
any-io-neurotic  oedema. 

Peripheral  neuritis  has  been  found  in  a  few  instances  of  symmetrical  gan- 
grene, and  there  are  instances  in  which  the  affection  was  a.ssociated  with  wrist- 
drop. In  a  recent  ca.se  the  patient,  an  alcoholic,  had  had  for  some  time  numb- 
ness and  tinsrlino;  and  formication  in  the  hands  and  feet.  This  was  followed  by  a 
condition  of  the  most  intense  local  asphyxia  of  the  hands  and  of  the  toes,  and 
scattered  patches  reseml)ling  erythema  nodosum  upon  the  skin  of  the  extrem- 
ities and  the  trunk.  Together  with  the.se  symptoms  there  were  slight  articular 
pains  and  swelling  of  the  right  knee,  so  that  the  condition  resembled  somewhat 
peliosis  rheumatica.  Urticaria,  erythema  nodosum,  and  scleroderma  have 
been  described  in  connection  with  this  affection. 

Amons-  the  most  remarkable  are  the  cerebral  manifestations.  Mental  tor- 
por  and  transient  loss  of  consciousness  have  been  described.  In  the  case 
above  mentioned  with  hemoglobinuria  the  patient  had  ei)il('ptic  .'seizures  with 
the  attacks.  Exposure  on  a  cold  day  would  bring  on  a  fit,  with  local  asjihyxia 
of  the  ear-tips  and  bloody  urine.  Acute  mania  has  developed,  and  delusions. 
A  case  has  recently  been  under  observation  in  which  during  the  attack  theiv 
was  aphasia  with  temi)orary  hemiplegia.  Dimness  of  vision  has  been  noted, 
and    retinal    changes,    chiefly    great    ii:in-(twing    of    the    arteries,    have    becMi 

de.'^cribed. 

The  pathology  of  this  remarkable  di.<ease  is  not  very  clear.  Ivayuaud 
suggested  that  the  local  a>|»iiyxia  was  caused  by  contraction  of  tlie  vessels, 
which  prohablv  in  the  extreme  grades  of  local  synco|)e  in\ulve^  :iit(rlcs.  veins, 
and  eaijiilarif's.  The  asphyxia  is  dep.Mi.ieiit  npuii  (iilatation  of  the  capillaries 
and  small  veins,  pn.bably  wit  li  the  j)(i-sist<'iice  dl"  some  spasm  in  t  lie  arterioles. 
Necro.sis  onlv  follows  when   the  condition  is  |»ersislent,  and   in   I  he  prolongcxl 


862  VASO-MOTOR    AND    TROPHIC  DISORDERS. 

stasis  the  vitality  of  the  tissues  becomes  lowered  beyond  power  of  restitution. 
In  all  probability  the  remarkable  cerebral  symptoms  are  caused  by  local  spasm 
in  special  vascular  territories. 

Treatment. — So  far  as  my  own  experience  goes  in  a  number  of  protracted 
cases,  internal  remedies  have  little  or  no  influence.  When  hsemoglobinuria 
has  been  present  and  anaemia  develops,  iron  should  be  given.  Galvanism  is 
recommended  by  Barlow,  who  advises  immersing  the  affected  limb  in  a  basin 
of  warm  salt  water,  in  which  the  negative  electrode  is  placed,  while  the  pos- 
itive is  applied  over  the  spine.  This  sometimes  relieves  the  pain.  In  an 
attack  the  affected  limb  should  be  raised  and  kept  wrapped  in  cotton  wool. 
The  pain  may  be  intense  enough  to  require  morphine.  As  the  condition 
improves  systematic  fricttons  with  sweet  oil  will  be  very  useful. 

Angio-neurotic  CEdbma. 
(Giant  Urticaria.) 

Definition. — A  disorder  characterized  by  an  outbreak  of  oedematous  swell- 
ing of  variable  extent,  sometimes  accompanied  by  gastro-intestinal  crises.  The 
disease  may  show  a  marked  hereditary  disposition. 

Symptoms. — The  most  common  situation  for  the  oedema  is  the  face,  and 
particularly  on  the  eyelids  ;  next  in  order,  the  nose.  In  obstinate  cases  it  may 
appear  on  any  part  of  the  body.  The  mucous  membrane  of  the  lips  and 
pharynx  may  be  attacked,  and  in  a  few  instances  there  has  been  sudden  and 
fatal  oedema  of  the  glottis.  The  oedema  may  reach  rapidly  a  very  high  grade, 
and  the  skin  is  tense,  shiny,  pale,  and  on  pressure  pits  readily.  Usually  the 
condition  is  transient  and  the  oedema  disappears  within  a  few  hours.  The 
onset  may  be  abrupt  without  any  previous  distress.  In  many  instances  the 
attack  only  occurs  when  there  is  gastric  disturbance.  The  disease  may  recur 
with  curious  periodicity  ;  thus  in  the  case  described  by  Matas  the  attack  came 
on  every  day  at  eleven  or  twelve  o'clock.  The  hereditary  form  is  very 
remarkable.  In  the  family  described  by  me  twenty-two  members  were 
affected  in  five  generations.  The  swellings  appeared  in  various  parts,  usually 
on  the  hands,  face,  or  genitalia.  Heat,  redness,  itching,  and  in  some  instances 
true  urticaria,  preceded  the  outbreak.  Two  members  of  the  family  died  of 
oedema  of  the  glottis.  In  all  the  cases  in  this  group  the  gastro-intestinal 
symptoms  were  most  pronounced — colicky  pains,  nausea,  vomiting,  and  some- 
times diarrhoea.  The  colic  was  severe  enough  to  require  hypodermics  of 
morphine. 

Quincke  regards  the  condition  as  a  vaso-motor  neurosis  causing  sudden 
increase  in  the  permeability  of  the  vessels.  The  affection  has  close  affinity 
with  urticaria  and  with  the  form  of  purpura  associated  with  gastro-intestinal 
crises  and  arthritis. 

The  treatment  should  consist  of  general  tonics.  Strychnine,  antifebrin, 
and  antipyrine  may  be  tried,  as  they  sometimes  seem  to  have  marked  influence 
in  checking  the  outbreaks  of  urticaria.     The  diet  is  of  great  importance  in  the 


PLATE    III. 


Case  of  Acromegaly  (Marie). 


A  CROMEGA  L  Y.  863 

cases,  and  the  outbreaks  may  be  detinitely  connected  with  indigestion  or  with 
overeating.  Local  treatment  is  not  of  much  vahie.  Wlien  the  oedema  is  very 
great  and  the  tension  painful,  careful  puncturing  gives  relief. 

Acromegaly. 

Definition. — An  affection  characterized  by  iiypertrophy  of  the  hands,  feet, 
and  face.  Tiie  name,  which  signifies  large  extremities,  was  given  by  Marie 
of  Paris. 

Etiology. — The  condition  occurs  more  frequently  in  women.  Of  38  cases 
in  the  monograj)h  of  Sousa-Leite,  22  were  in  women  and  IG  in  men.  The 
affection  begins,  as  a  rule,  at  about  the  twenty-fifth  year,  occasionally  earlier, 
in  .some  instances  as  late  as  the  fortieth.  It  has  no  apparent  connection  with 
sexual  processes.  Heredity  has  ai>parently  played  a  part  in  some  cases. 
Syphilis,  the  specific  fevers,  and  rheumatism  iiave  occasionally  preceded  the 
development  of  the  disease,  but  probably  have  no  special  connection  with  it. 
In  this  country  only  a  few  ca.ses  have  been  reported. 

Symptoms. — A  well-marked  case  presents  a  very  characteristic  aj^pearance. 
(Sec  Plate  III.)  The  hands  and  feet  are  enlarged,  the  increase  in  size  involving 
both  bones  and  soft  parts  and  giving  a  spade-like  character  to  the  hands.  The 
wrists  may  be  enlarged,  but  the  arms  are  not  often  affected.  Tiie  feet  are  uni- 
formly enlarged,  and  the  size  of  the  big  toe  has  been  in  some  cases  out  of  pro- 
portion to  the  others.  The  nails  arc  usually  broad  and  large  and  vertically 
grooved.  Although  they  look  clumsy  and  unwieldy,  the  hands  fan  be  used 
freely,  and  even  such  a  delicate  operation  as  threading  a  needle  can  be  well 
performed.  The  long  bones,  as  a  rule,  are  unaffected,  but  in  some  instances 
there  has  been  thickening  of  the  extremities  of  the  fenuu-  and  of  the  tibia 
and  the  fibula.  The  enlargement  involves  the  head  and  face,  particularly  the 
latter,  which  becomes  elongated  and  broadened  in  consequence  of  the  increase 
in  size  of  the  superior  and  inferior  maxillary  bones  ;  the  latter  in  particular 
increases,  and  may  ])roject  beyond  the  nppcr  Jaw.  The  alveolar  processes 
become  greatly  thickened  and  the  teeth  are  separated.  The  lc)wer  li|>  is 
thickened  and  the  ears  greatly  hypertrophied.  The  tongue  has  in  some 
instances  been  greatly  enlarged.  Increase  in  the  si/e  of  the  bones  of  the 
skull  may  be  present.  The  neck  looks  short  and  thick,  chiefly  on  account 
of  the  elongati(m  and  depression  of  the  chin.  The  skin  may  look  nornud  or 
is  coarse  and  flaljby.  It  rarely  has  the  harsh  appearance  of  myxocdema,  and 
the  subcutaneous  tissues  are  not  infiltrated.  The  bones  of  the  thorax  may 
slowly  and  progressively  enlarge,  and  in  a  late  stage  of  the  disease  the  spinal 
column  may  be  involved  and  there  may  be  marked  kyi)hosis.  The  clavicles 
and  sternum  may  also  increase  in  size.  The  muscles  arc  sometimes  wasted. 
The  irenitalia  have  sometimes  been   hvpertroi)hied. 

The  thyroid  has  been  normnl  in  some  cases,  atro|)hie(l  in  others,  ;ind  in  a 
third  group  eidarged.  Krb  has  noticed  an  aica  of  dnlness  over  tlic  nianni)rium 
sterni  which  he  thought  to  be  possibly  due  to  persistence  of  flic  I  hymns.  In 
women  menstrual  distin-bance  may  be  an  early  fi-alnrc,  and  there  may  be  com- 


864  VASO-MOTOB   AND    TROPHIC  DISORDERS. 

plete  suppression.  The  voice  changes,  partly  on  account  of  the  enlargement 
of  the  tongue,  partly  because  of  changes  in  -the  laryngeal  cartilages.  Patients 
often  complain  of  headache.  There  may  be  increasing  dimness  of  vision,  ow- 
ing to  a  progressive  atrophy  of  the  optic  nerve.  Less  commonly  the  sense 
of  hearing  and  smell  are  deficient.  The  disease  may  last  from  ten  to  twenty 
years:  a  condition  of  cachexia  ultimately  develops  and  the  patient  dies  of 
exhaustion. 

The  morbid  anatomy  of  the  disease  has  been  studied  in  several  cases. 
The  enlargement  of  the  bones  is  a  true  hypertrophy.  The  increase  in  the 
size  of  the  face  is  largely  due  to  dilatation  of  the  antrum.  The  lesions  are 
essentially  different  from  those  of  the  osteitis  deformans  of  Paget,  in  which 
the  shafts  of  the  bones  are  chiefly  involved,  and  also  from  arthritis  deformans. 
The  pituitary  body  has  been  found  hypertrophied ;  less  commonly  changes 
occur  in  the  thymus  and  thyroid.  The  peripheral  nerves  have  been  found 
deffenerated  in  several  cases.  The  nature  of  the  disease  is  still  in  doubt. 
According  to  Marie,  it  is  a  systemic  dystrophy  analogous  to  myxoedema,  and 
associated  possibly  with  the  changes  in  the  pituitary  body,  just  as  myxoedema 
is  connected  with  disease  of  the  thyroid  gland.  The  most  exhaustive  descrip- 
tion of  the  pathological  anatomy  and  a  discussion  of  the  relation  of  the  affec- 
tion to  other  forms  of  enlargement  of  the  bones  will  be  found  in  the  essay  of 
Arnold  of  Heidelberg.^ 

Diagnosis. — The  disease  must  not  be  confused  with  myxoedema,  in  which 
the  bones  are  not  enlarged.  It  is  most  likely  to  be  confounded  with  the 
osteitis  deformans  of  Paget,  in  which  disease,  however,  the  shafts  of  the  long 
bones  are  chiefly  affected,  and  in  the  head  the  cranial,  not  the  facial,  bones  are 
enlarged.  In  the  cases  of  congenital  progressive  hypertrophy,  the  so-called 
giant  growth,  as  a  rule,  only  a  single  member  is  involved  and  the  shafts  of 
the  long  bones  are  affected.  According  to  Marie,  the  face  in  Paget's  disease 
is  triangular,  with  the  base  upward  ;  in  acromegaly  it  is  ovoid  or  egg-shaped, 
with  the  large  end  downward  ;  in  myxoedema  it  is  round  and  full-moon- 
sha])ed.  Marie  has  separated  a  group  of  cases  characterized  by  hypertrophy 
of  the  bones  of  the  extremities  and  of  the  shafts,  associated  in  some  way  with 
disease  of  the  lungs.  The  condition  of  the  fingers  differs  from  that  of  ac- 
romegaly, as  the  phalanges  are  bulbous  and  enlarged  and  the  nails  curved, 
very  different  from  the  flattened  terminal  phalanges  of  acromegaly.  Curva- 
ture of  the  spine  is  also  common.  The  cases  have  been  met  with  in  connection 
with  purulent  pleurisy,  with  new  growths  in  the  lungs,  and  with  chronic 
bronchitis.  Marie  terms  it  osteo-arthropathie  pneumique.  Arnold  does 
not,  however,  regard  this  as  a  form  which  can  be  definitely  separated 
from  acromegalv.  iL 

A  curious  dystrophy,  met  with  only  in  women,  involving  the  fingers  and 
toes,  is  the  sclerodactylo.  The  lesions  are,  as  a  rule,  symmetrically  dis- 
tributed. The  fingers  are  atrophied  and  shortened,  the  skin  is  thickened 
and  waxy,   and  the   nails  are  deformed  and   small  and  often  curved.     The 

'  Zlcf/ler's  Beitrage,  1891. 


SCLEB01JIJR3fA.  8G5 

fingers  may  be  di.slocated,  and  the  joints  become  ankylosfed  in  irregular 
positions,  so  that  the  fingers  are  distorted.  Ankylosis  of  the  wrist  and  of 
the  ankle  have  been  observed.  In  some  instances  there  have  been  diffuse 
sclerodermatous  changes  in  the  skin  in  other  parts.  The  causation  of  the  dis- 
ease is  unknown.  Many  of  the  patients  have  suffered  severely  with  cold,  and 
the  condition  is  much  worse  during  the  winter.  In  the  only  autopsy  which 
has  been  made  no  clue  was  obtained  as  to  the  natui-e  of  the  trouble.  A  good 
description  of  the  disease  has  been  given  by  Gordinier.* 

No  treatment  has  been  found  of  anv  avail  in  acromegalv  or  tlie  allied 
conditions. 

Scleroderma. 

A  condition  in  which  the  skin  becomes  tense  and  hard,  either  in  circum- 
scribed patches  or  in  extensive  diffuse  areas.  These  two  forms,  the  circum- 
scribed and  the  difiuse,  may  exist  together  or  separately.  The  circumscribed 
scleroderma  corresponds  to  the  affection  known  as  morphoea  and  to  the  keloid 
of  Addison.  In  patches  ranging  from  half  a  centimetre  in  diameter  to  the 
size  of  the  hand  the  skin  is  hard,  brawny,  inelastic,  and  has  a  waxy,  dead- 
white  appearance.  These  patches  occur  most  frequently  in  women  about  the 
breasts  and  neck,  occasionally  in  the  course  of  the  nerves  either  in  the  trunk, 
the  intercostal,  or  lumbar,  and  on  the  face  in  the  branches  of  the  fifth.  A 
preliminary  hypersemia  may  precede  the  development  of  tlie  patches,  and  in 
some  instances  there  are  changes  in  color  due  to  increase  in  the  })igtnent  of  the 
skin.  In  other  cases  there  is  complete  atrophy  of  the  pigment  and  leucotlerma. 
Preceding  the  onset  there  may  be  itching  or  irritation  of  the  skin,  and,  when 
fully  developed,  anaesthesia  is  occasionally  present.  The  sweat  secretion  is 
either  diminished  or  completely  abolished.  There  are  instances  in  which  the 
disease  begins  with  the  development  of  small  linear,  cicatricial-likc  spots — 
lineae  atrophicse.  A  curious,  remarkable  feature  is  the  rapidity  with  which 
the  patches  appear  and  their  variability.  They  may  persist  for  months  or 
years  with  but  slight  change,  and  after  lasting  for  some  time  may  disapj)ear 
in  a  few  weeks.  According  to  Crocker,  "The  pathology  appears  to  be  that, 
owing  probablv  to  some  defect  in  innervation,  an  exudation  occurs  round  the 
vessels,  narrowing  tlif  lumen,  obstructing  therefore  the  blood-flow,  and  lead- 
ing to  thrombosis  and  sometimes  to  a  real  rupture  and  effusion.  Kach  atr(»- 
phic  s])ot  seen  near  a  growing  patch  is  the  base  of  a  cone  from  which  the 
i)lood-supplv  is  cut  off,  the  violet  zone  being  due  to  collateral  liypcraMuia 
round  an  aiucmic  area.  The  patch  or  atrophic  sjjot  thickens  by  the  fibrilla- 
tion of  the  effused  cells.  AVlier(>  the  arterial  su))j)ly  is  completely  cut  off  an 
atrophic  spot  is  produced  ;  where  it  is  merely  diminished  partial  atn.|tliy,  with 
connective- tissue  hyi)er|)lasia,  or  riior|»h(pa,  is  the  residt." 

The  diffuse  scleroderma  is  more  rare.  It  :i]t]tears  first  in  the  extremities  or 
on  the  fa«-e,  and  the  skin  becomes  hard  and  tense,  so  that  the  |)alienl  has  great 
diffieultv  ill  performing  ordinary  moveinents.  When  fully  developed  there  is 
a   brawnv  induration    of  such   a  degree   of  linunes^   that    the  skin   eamiot   be 

'  Arnericnn  Journal  of  tlf  Mnlirul  Srlijtnt^,  Jan.,  1889. 
Vol,.  I.— 55 


866  VASO-3IOTOB    AND    TROPHIC  DISORDERS. 

picked  np  or  pinched.  The  wrinkles  are  effaced  and  the  skin  looks  stretched, 
dry,  and  glossy.  Dinkier,  who  has  recently  made  a  careful  study  of  the  con- 
dition from  Erb's  clinic,  states  that  of  44  cases,  in  24  the  first  appearances  were 
on  the  arms ;  in  7  on  the  legs,  in  1  on  both  ;  in  10  on  the  face  and  neck ;  and 
in  2  on  the  trunk.  Gradually  extending,  the  disease  may  involve  the  greater 
portion  of  the  skin  of  the  trunk  or  that  of  an  entire  limb.  Occasionally  it 
becomes  universal.  The  joints  are  fixed  in  semiflexion,  and  movements  are 
impossible  on  account  of  the  hidebound  condition.  The  face  is  expressionless, 
immobile,  and  it  may  be  almost  impossible  for  the  patient  to  chew  his  food. 
The  sensory  changes  are  not  marked,  but  during  the  development  of  the  affec- 
tion there  may  be  great  itching.  The  mucosa  of  the  mouth  and  pharynx  has 
been  occasionally  involved.  The  disease  persists  for  months  or  years,  and 
there  are  instances  on  record  of  its  persistence  for  more  than  twenty  years. 

The  disease  is  sometimes  arrested,  and  in  a  few  instances  recovery  has  fol- 
lowed. Death  usually  results  from  intercurrent  pulmonary  affection  or  from 
nephritis.  The  nature  of  the  disease  is  unknown.  Some  cases  have  been  pre- 
ceded by  rheumatism ;  others  have  been  met  with  in  connection  with  endo- 
carditis and  rheumatic  nodules.  It  is  generally  regarded  as  a  tropho-neurosis, 
possibly  depending  upon  changes  in  the  arteries  of  the  skin,  and  so  leading  to 
connective-tissue  overgrowth. 

As  the  patients  are  particularly  sensitive  to  changes  in  the  weather  and  to 
cold,  they  should  be  warmly  clad,  and  when  possible  live  in  a  mild  climate. 
Frictions  with  oil  and  electricity  have  been  recommended,  and  in  the  local  forms 
galvanism  seems  to  have  been  beneficial. 

Allied  to  scleroderma  is  the  remarkable  affection  known  as  sclerema  neona- 
torum, in  which,  either  at  birth  or  shortly  after,  there  are  large  areas  of  indu- 
ration of  the. skin,  which  is  tense  and  glossy  and  does  not  pit  on  pressure.  It 
is  sometimes  associated  with  oedema  of  the  subcutaneous  tissues.  The  disease 
may  spread  rapidly,  and  the  congenital  cases  are  usually  fatal.  Recovery, 
however,  is  not  impossible.  In  a  remarkable  case  recently  seen  with  Dr. 
Ellis  of  Elkton  a  healthy,  well-grown  child  of  two  and  a  half  months  had 
an  acute  pleuro-pneumonia,  during  which,  on  the  sixth  day,  it  developed  gen- 
eral scleroderma,  the  entire  skin  becoming  hard  and  leathery,  the  legs  stiff, 
and  the  whole  body  looking  rather  like  a  model  of  a  child  in  wax. 

Facial  Hemiatrophy. 

This  is  a  rare  affection,  and  less  than  one  hundred  cases  have  been  reported 
in  the  literature.  The  wasting  is  on  one  side  of  the  face — hence  the  name — 
is  progressive  in  character,  and  involves  bones  and  soft  tissues.  It  begins,  as 
a  rule,  in  childhood,  and  the  onset  may  be  accompanied  by  pains  and  j)ar8es- 
thesia.  It  may  start  at  one  or  two  spots  on  the  skin  and  gradually  spread,  or 
begin  diffusely  and  gradually  involve  soft  parts  and  bones.  The  atrophy  is 
strictly  confined  to  one  side,  and  when  fully  developed  gives  a  remarkable 
appearance  to  the  patient,  whose  face  looks  made  up  of  two  unsymmetrical 
halves.     The  atrophy  is  strictly  limited  to  the  middle  line.     Sensibility  is  not 


FACIAL    HEMIArROPHY.  867 

affected.  The  skin  may  be  tlarker  in  color  ami  the  hair  falls  out.  The  teeth 
may  become  loose,  owing  to  wasting  of  the  alveolar  i)rocesses.  The  move- 
ments of  the  muscles  are  rarely  aifected,  though  in  Sachs'  patient  there  were 
tonic  and  clonic  contractures  of  the  temporal  and  masscter  muscles.  The 
nature  of  the  disease  is  still  doubtful.  In  the  autopsy  in  IToman's  case, 
which  came  on  rapidly  and  can  scarcely  be  regarded  as  a  typical  illustration,  a 
tumor  was  found  pressing  upon  the  Gasserian  ganglion  and  the  fifth  nerve. 
In  Mendel's  case  there  was  an  interstitial  neuritis  in  all  the  branches  of  the 
trigeminus  from  its  origin  to  the  periphery,  most  advanced  in  the  superior 
maxillary  branch.  The  disease  is  probably  due  to  involvement  of  the  troj>hic 
fibres  of  the  fifth  nerve. 

The  prognosis  is  unfavorable,  as  the  affection  is  progressive.  The  cases 
of  facial  asvmmetrv  in  children  associated  with  congenital  wrv-neck  must  not 
be  confounded  with  progressive  facial  hemiatrophy. 


INDEX. 


ABASIA-ASTASIA,  diugnosis  of,  from 
locomotor  ataxia,  784 
Abdomen,  large,  in  scrofula,  341 

protuberant,    in     pseudo-hypertrophic 
muscular  atropby,  854 
Abdominal  form  oi"  typhoid  fever,  102 

pain  in  trichinosis,  507 

in  typhoid  fever,  67,  83 

reflex,  524 
Abducens  nerve.     See  Sixth  Nerve. 
Abductor  paralysis,  bilateral,  836 

unihiteral,  836 
Abortion  in  relapsing  fever,  158 

in  syphilis,  361 

in  typhoid  fever,  97 

in  yellow  fever,  456 
Abortive  form  of  cerebro-spinal  fever,  170 
of  scarlatina,  220 
of  typhoid  fever,  99 
Abscess  of  brain,  714 

of  muscles  in  typhoid  fever,  64 

of  parotid,  309 

of  spinal  cord,  747 
Abscesses  in  glanders,  514 

typhoid  bacilli  in,  56 

in  typhoid  fever,  90 

in  ty|>hus  fever,  145 
Abscesses,  multiple,  in  actinomycosis,  475 

secondary,  in  pviemia,  327 
Abulia,  530 

Acetanilid  in  typiioid  fever,  123 
Achr<)mato[)sia  in  iiysteria,  601 
Acids  in  typhoid  fever,  132 

in  typhus  fever,  149 
Aconite  in  cerebro-spinal  fever,  183 

in  influenza,  195 

in  typhoid  lever,  124 
Acromegaly,  863 

definition  of,  863 

diagnosis  of,  864 

etiology  of,  863 

morbid  anatomy  of,  864 

symptomatology  of,  863 
Acromegalv,  diagnosis  of,  from  myxredema, 
X64 
from  osteitis  deformans,  864 
Actinomyces,  473 

in  etiology  of  actinomycosis,  473 
Actinomycosis,  473 

definition  of,  473 

diagnosis  of,  477 

etiology  of,  473 

metastasis  in,  476 

pathology  of,  475 


Actinomycosis,  prophylaxis  of,  477 
surgical  measures  in,  477 
symptomatology  of,  476 
treatment  of,  477 
Actual  cautery  in  bites  of  rabid  animals, 

496.     See,  also,  Coutitcr-irritanU. 
Acupuncture  in  sciatica,  849 
Acute  ascending  paralysis,  748 
definition  of,  748 
diagn(»sis  of,  751 
etiology  of,  748 
pathology  of,  750 
jirognosis  of,  751 
reflexes  in,  749 
sym])tomatology  of,  749 
treatment  of,  751 
Acute   ascending    paralysis,   diagnosis   of, 
from  acute  myelitis,  756 

from  acute  poliomyelitis, 
768 
Acute  hydrocephalu:?.  See  Tuberculous  Men- 
ingitis. 
Acute  miliary  tuberculosis.    See  Tuberculo- 

s/.v,  Acnlr  Mllnn-ij. 
Acute  periencephalitis.     See  Periencepka li- 
tis, Acute. 
Acute  yellow  atrophy,  diagnosis  of,  from 

yellow  fever,  458 
Addison's  keloid.     See  Scleroderma. 
Adynamic  form  of  typhoid  fever,  102 

of  typhus  fever,  144 
^sthesiometer,  527 
Afebrile  form  of  typhoid  fever,  100 
African  sleeping  disease.     See  Nelnvan. 
Agaricin  in  sweats  of  j)ya3mia,  328 
Age  in  etiology  of  aernniegaiy,  863 

of  cereliral  haiiiorrliage,  679 

of  cerebro-spinal  fever,  164 

of  diphtheria,  378 

of  epilepsv,  612 

of  hysteri'a,  593 

of  leprosy,  369 

of  locomotor  ataxia,  777 

of  measles,  234 

of  miliary  fever,  201 

of  mumps,  305 

of  myositis  ossilieans,  851 

of  paramyoclonus  multiplex,  857 

of  aeiile  poliomyelitis,  761 

of  progressive  muscular  atrophy, 

799 
of  relapsing  fever,  151 
of  riil)ella,  255 
of  scarlatina,  210 

tfStt 


870 


INDEX. 


Age  in  etiology  of  scrofula,  337 
of  small-pox,  263 
of  St.  Vitus's  dance,  628 
of  syringomyelia,  772 
of  acute  miliary  tuberculosis,  329 
of  typhoid  fever,  54 
of  typhus  fever,  135 
of  varicella,  298 
of  whooping  cough,  313 
of  yellow  fever,  453 
Age,  influence  of,  upon  typhoid  fever,  103 
Ageusia,  835 
Agraphia,  704 

Agriculturalists,  mortality  of,  26 
Ague.     See  Malarial  Fevers. 
Ague-cake,  412 

Albuminuria  in  cerebral  haemorrhage,  682 
in  cerebro-spinal  fever,  169,  176 
in  cholera,  443 
in  diphtheria,  383 
in  erysipelas,  400 
in  measles,  244 
in  pyaemia,  327 
in  Raynaud's  disease,  861 
in  relapsing  fever,  158,  1.60 
in  scarlatina,  218 
in  acute  miliary  tuberculosis,  332 
in  typhoid  fever,  89,  97,  102 
in  typhus  fever,  139,  143,  144,  146 
in  yellow  fever,  456 
Albuminuric  retinitis,  224,  814 
Alcohol  in  delirium  tremens,  561 
in  diphtheria,  395 
in  erysipelas,  403 
in  simple  insomnia,  661 
in  measles,  252 
in  pyaemia,  328 
in  septicaemia,  326 
in  typhoid  fever,  116 
in  typhus  fever,  148 
Alcoholic  insanity,  561 
forms  of,  562 
symptomatology  of,  561 
neuritis.     See  Neuritis,  Multiple  Alco- 
holic. 
Alcoholism,  acute,  diagnosis  of,  from  cere- 
bral  haemorrhage,    686.     See,   also. 
Alcoholic  Insanity  and  Delirium  Tre- 
mens. 
Alexia,  704 
Algesia,  527 

Algid  form  of  malarial  fever,  427 
Alkaloids  in  urine  of  scarlatina,  214 
Allocheiria  in  locomotor  ataxia,  780 
Alopecia  in  facial  hemiatrophy,  867 
in  syphilis,  353 
following  typhoid  fever,  90 
typhus  fever,  145 
Alternate   hemiplegia  in  cerebral  haemor- 
rhage, 684 
Altitude  and  disease,  27 

in  etiology  of  cerebro-spinal  fever,  164 
of  influenza,  186 
of  malarial  fever,  411 
of  yellow  fever,  452 
symptoms  produced  by  a  high,  207 


Alum  in  epistaxis,  131 

in  purification  of  water,  35 
in  typhoid  fever,  131 
Amaurosis,  hysterical,  605,  815 
diagnosis  of,  605 
quinine,  815 

in  Raynaud's  disease,  861 
saturnine,  815 
in  scarlatina,  219,  223 
tobacco,  815 
uraemic,  815 
Amblyopia  in  acromegaly,  864 

in  hysteria,  601 
Ambulatory  form  of  typhoid  fever,  101 
Amenorrhcea  following  typhoid  fever,  97 
Ammonia  in  cerebro-spinal  fever,  183 
in  influenza,  195 
in  relapsing  fever,  161 
Ammonium  acetate  in  typhoid  fever,  124 
carbonate  in  typhoid  fever,  132 
in  typhus  fever,  149 
Amnesia,  auditory,  704 

visual,  703 
Amoeba  dysenteriae,  9 
Amyloid  disease  in  actinomycosis,  477 

in  syphilis,  352 
Amyotrophic  lateral  sclerosis,  794,  852 
definition  of,  794 
etiology  of,  794 
pathology  of,  794 
prognosis  of,  795 
symptomatology  of,  794 
treatment  of,  795 
Anaemia  following  diphtheria,  386 
in  malarial  cachexia,  432 
following  relapsing  fever,  159 
■     in  syphilis,  358 
in  typhoid  fever,  72 
following  typhoid  fever,  78,  93 
Anaesthesia  in  cerebral  haemorrhage,  685 
in  cerebro-spinal  fever,  172 
in  diphtheritic  paralysis,  384 
in  haematorrhachis,  741 
in  hysteria,  600 
in  leprosy,  371 
in  local  asphyxia,  859 
in  locomotor  ataxia,  780 
in  Morvan's  disease,  775 
in  multiple  alcoholic  neuritis,  808 
in  myelitis,  754 

in  paralysis  of  anterior  crural  nerve, 
846 
of  fifth  nerve,  825 
of  median  nerve,  844 
of  pneumogastric  nerve,  836 
of  ulnar  nerve,  845 
in  relapsing  fever,  158 
in  scleroderma,  865 
in  spinal  apoplexy,  746 

tumor,  748 
in  syringomyelia,  773 
in  tetany,  638 
in  typhoid  fever,  81 
Anaesthesia  dolorosa,  748 
Analgesia  in  cerebral  haemorrhage,  685 
in  hysteria,  600 


INDEX. 


871 


Analgesia  in  Morvan's  disease,  775 
in  syringomyelia,  773 
in  tetany,  638 
Anarthria,  701 
Anasarca.     See  CEdrnia. 
Anchylostomum  duodenale,  9 
Anemometer  in  testing  ventilation,  42 
Aneurism  of  cerebral  arteries,  693 
Angina  in  scarlatina,  215,  217 
Angina  Ludovici  in  actinomycosis,  476 

in  scarlatina,  224 
Angina    pectoris,    diagnosis    of,    from    the 
cardiac  crises  of  locomotor   ataxia, 
785 
pseudo-  or  hysterical,  601 
Anginose  scarlatina,  220 
Angio-neurotic  Q3dema,  862 
definition  of,  862 
symptomatology  of,  862 
treatmentof,  862 
Animal  lymph,  292 
Animals,  anthrax  in,  479 

apparent  occurrence  of  dengue  in,  197 
glanders  in,  512 

production  of  relapsing  fe,  .  152 

scarlatina  in,  213 
Anisocoria,  821 

Ankle,  ankylosis  of,  in  sclerodactyle,  865 
Ankle  clonus,  525 

in  antero-lateral  sclerosis,  791 
in  epilepsy,  615 
in  hysterical  paraplegia,  599 
in  chronic  myelitis,  760 
Anomalous  epilepsies,  615 
Anorexia  in  diphtheria,  382,  386 
in  hysteria,  602,  605 
in  small-pox,  266 
in  typhoid  fever,  67,  82 
Anosmia,  etiology  of,  813 

in  cerebro-spinai  fever,  173 
Anterior  cerebral  artery,  occlusion  of,  691 
crural  nerve,  aftections  of,  846 
poliomyelitis.     See  PoHomi/eHfis. 
Antero-lateral  sclerosis,  790  , 

definition  of,  790 
diagnosis  of,  791 
'etiology  of,  790 
pathology  of,  790 
[trognosis  of,  703 
symptomatology  of,  790 
synonyms  of,  790 
treatinent  of,  793 
Antero-lateral  sclerosis,  diagnosis  of,  from 

liysterical  contractures,  792 
Anthrax,  478 

in  lower  animals,  479 
bacillus  of,  478 
cause  of,  11,  478 
definition  of,  478 
diagnosis  of,  482 
etiology  of,  478 
intestinal  form  of,  481 
morbid  anatomy  of,  480 
mortality  of,  4.S2 
prognosis  of,  482 
I)rojjliylaxis  of,  482 


Anthrax,  symptomatology  of,  480 

synonyms  of,  478 

thoracic  form  of,  481 

treatment  of,  483 
Anthrax,    diagnosis    of,    from    carbuncle, 
482 
from  ervsipehus,  482 
Anthrax  bacillus,  478 

cultivation  of,  479 
destruction  of,  16,  479 
in  etiologv  of  anthrax,  11,  478 
in  soil,  29,  480 
Anthrax  cvdema,  481 
Anthrax  with  typhoid  fever,  97 
Antifebrin  in  angio-neurotic  oedema,  862 

in  epilepsy,  624 

in  locomotor  ataxia,  787 

in  relapsing  fever,  161 

in  scarlatina,  228 

in  small- pox.  282 
Antipyretics  in  influenza,  194 

in  scarlatina,  228 

in  small-pox.  282 

in  typhoid  fever,  122 

in  typhus  fever,  149 
Antipyrine  in  angio-neurotic  cedema,  862 

in  cerebro-spinai  fever,  183 

in  dengue,  200 

in  ephemeral  fever,  50 

in  epilepsy,  625 

in  influenza,  194 

in  locomotor  ataxia,  787 

in  rela])sing  fever,  161 

in  scarlatina,  228 

in  small-i)ox,  282 

in  typhoid  fever,  127 

in  ty|)hus  fever,  149 

in  whooping  cough,  321 
Antiseptics,  16 

in  typhoid  fever,  125 
Antispasmodics  in  hysteria,  608 
Antitoxines  in  anthrax,  483 

in  tetanus,  470 
Antrum,  dilatation  of,  in  acromegaly,  864 
Anuria  in  hysteria,  602 

significance  of,  in  scarlatina,  219,  220 

in  tetanus,  467 
Aphasia,  701 

in  brain  syi)hilis,  729 

in  brain  tumor,  72(1 

in  cerebral  haemorrhage,  684 

following  cerebro-spinai  fever,  177 

of  coiidiictioii,  7'*5 

in  infantile  hemiplegia,  707 

localization  of  lesion  in,  705 

temporary,  in  migraine,  658 

mixed  forms  of,  704 

motor,  704 

in  Raynaud's  disease,  861 

sensorv,  702 

tests  for,  705 

treatment  of,  705 

following  typiioid  fever,  91 
A{)honia  in  adductor  paralysis,  836 

in  diphtheria,  381,  382   ' 

in  hysteria,  6(i2 


872 


INDEX. 


Aphonia  in  trichinosis,  506 
Apomorphine  in  convulsions,  627 

in  hiccough,  841 
Apoplectic  cerebro-spinal  fever,  169 
Apoplexy,   ingravescent,   683.      See,   also, 

Cerebral.   Hcemorrkage. 
Apraxia.     See  Aphasin,  Sensory. 
Arachnoid,   changes   in,   in   cerebro-spinal 

fever,  167 
Aran-Duchenne  tvpe  of  muscular  atrophy, 

852 
Ardent  continued  fever,  48,  646 
Argyll-Robertson  pupil,  821 

in  locomotor  ataxia,  782 
Arm,  peripheral  paralysis  of,  841 
Arsenic  in  cerebro-spinal  fever,  183 
in  epilepsy,  625 
in  relapsing  fever,  161 
in  St.  Vitus's  dance.  632 
in  trifacial  neuralgia,  827 
in  the  coloring  of  wall-paper,  23 
Arteries,  embolism  and  thrombosis  of  cere- 
bral, 688 

of  anterior  cerebral,  691 
of  basilar,  691 
of  internal  carotid,  691 
V   of  middle  cerebral,  691 
of  posterior  cerebral,  691 
of  vertebral,  691 
occlusion  of,  in  typhoid  fever,  93 
Artery  of  cerel)ral  haemorrhage,  679 
Arthritis  in  cerebro-spinal  fever,  171 
in  locomotor  ataxia,  782 
in  localized  neuritis,  806 
in  scarlatina,  218 
in  small-pox,  277 
in  typhoid  fever,  90 
Arthritis,  diagnosis  of,  from  hysterical  joint, 

603 
Arthro{)athies  in  hemiplegia,  686 
in  locomotor  ataxia,  782 
in  Morvan's  disease.  775 
Asafoetida  in  cerebro-spinal  fever,  182 
in  typhoid  fever,  128,  130 
in  typhus  fever,  149 
Ascarides  as  a  cause  of  perforation  in  ty- 
phoid fever,  92 
Ascites  in  scarlatina,  219 
Asphyxia  in  cholera,  443 
in  diphtheria,  383 
in  thermic  fever,  664,  647 
Astasia-abasia,  diagnosis  of,  from  locomotor 

ataxia,  784 
Asthenic  form  of  malarial  fever,  427 
Ataxia,  cerebellar,  722 

in  diphtheritic  paralysis,  384 
in  Friedreich's  ataxia,  797 
hereditary,  795 
in  insular  sclerosis,  712 
locomotor,  776 

in  chronic  periencephalitis,  554 
in  Thomsen's  disease,  857 
Ataxic  aphasia.     See  Aphasia,  Motor. 
gait,  780 
nystagmus,  798 
Ataxic  paraplegia,  793  , 


Ataxic  paraplegia,  definition  of,  793 
etiology  of,  793 
pathology  of,  793 
prognosis  of,  794 
symptomatology  of,  794- 
treatnient  of,  794 
Ataxic  paraplegia,  diagnosis  of,  from  Fried- 
reich's ataxia,  793,  794 
Ataxic  form  of  typhoid  fever,  102 

of  typhus  fever,  144 
Atelectasis  in  cerebro-spinal  fever,  176 
Athetosis  in  infantile  hemiplegia,  708 
Atmospheric  pressure  as  cause  of  disease, 

27 
Atrophic  paralysis,  772 

diagnosis  of,  from  subacute  polio- 
myelitis, 772 
Atrophy  in  ansesthetic  leprosy,  371 
in  Friedreich's  ataxia,  798 
in  hemiplegia,  686  " 
in  hypoglossal  paralysys,  840 
in  infantile  hemiplegia,  708 
in  locomotor  ataxia,  782 
in  Morvan's  disease,  775 
in  multiple  neuritis,  807 

alcoholic  neuritis,  808 
in  acute  myelitis,  755 
in  myositis,  850 
in  localized  neuritis,  806 
in  acute  poliomyelitis,  764 
in  chronic  poliomyelitis,  771 
in  progressive  muscular  atrophy,  801 
in  sciatica,  848 
in  syringomyelia,  774 
of  brain,  in  cerebral  palsies  of  children, 
707 

in  hgemorrhagic  pachymeningitis, 

670 
in  chronic  periencephalitis,  551 
unilateral,  707 
from  compression,  851 
of  deltoid  muscle,  in  circumflex  paraly- 
sis, 843 
in  inflammatory  conditions,  851 
Atropine  in  cholera,  449 

in  sweats  of  pyajmia,  328 
in  earache  of  scarlatina,  229 
Attention,  inability  to  fix  the,  532 
Attitude  in  pseudo-muscular  hypertrophy, 

854 
Auditory  aurse  in  epilepsy,  615 
centre,  lesions  of,  833 
nerves,  clianges   in,  in    cerebro-spinal 
fever,  167 
Aura,  forms  of,  in  epilepsy,  614 
Aural  vertigo,  611 
Automatic  chorea,  635 

definition  of,  635 
treatment  of,  637 
symptomatology  of,  635 
consciousness  in  hysteria,  596 
movements,  524 
Automatism,  epileptic,  616 

in  brain  syphilis,  728 
Autumnal  fever,  54 
Average  death-rates,  5 


i 


IXDEX. 


.^73 


BACILLUS  antliracis,  11,  16,  478 
of  cholera,  12,  435 
coli    coimiiunis,    resemblance    of,    to 

typhoid  bacillus,  5G 
diplitherine,  11,  373 
of  glanders,  11,  512 
of  hog  cholera,  12 
in  sputum  of  inHuenza,  185 
lepne.  11,  370 
malaria^,  407 
mallei.  11,  512 
scarlatiuw,  213 
of  tetanus,  11,  463 
tuberculosis,  11 

in  bone  lesions  of  scrofula,  340 
relation  of,  to  scrofula,  337 
tussis  convulsivoe,  313 
typhosus,  11,  55 
Bacteria,  classification  of,  11 
and  disease,  9 
in  sewage,  33 
in  sewer  air,  12 
Bacteriological  examination  of  water,  30 
Bakers,  mortality  of,  26 
Barracks,  proper  dimensions  of,  39 
Basal  ganglia,  tumors  of,  721 
Basilar  artery,   embolism   and   thrombosis 

of,  691' 
Bathing  in  scarlatina,  226,  227 
Baths  in  septicaemia,  326 
in  small-pox,  282 
cold,  in  cerebro-spinal  fever,  181 
in  ephemeral  fever,  50 
in  erysipelas,  403 
in  relapsing  fever,  161 
in  scarlatina,  228 
in  thermic  fever,  649 
in  typhoid  fever,  119 
in  typhus  fever,  148 
hot,  in  cholera,  447 

in  convulsions,  627 
in  simple  insomnia,  661 
in  chronic  myelitis,  761 
mercurial,  in  liereditary  sy[)hilis,  367 
warm,  in  diphtheria,  395 
in  locomotor  ataxia,  788 
in  measles,  251 
in  acute  myelitis,  757 
Bedding,  24  i 

disinfection  of,  17  i 

Bed-rooms,  proper  dimensions  of,  39 
Bed-sores  in  cerebral  lueniorrhage,  683 
in  cerebro-spinal  fever,  175,  183 
following  cholera,  444 
in  myelitis,  755 
in  pva-mia,  327 
in  tyi)hoid  h-v.-r,  89,  132 
Belladonna  in  cerebro-spinal  fever,  183 
in  scarhitiiia,  227 
in  typhoiil  lever,  125 
in  whooping  cough,  321 
Cell's  mania.     See  I'l'iiencep/i'i/ifix,  Acute. 

palsv.     See  FacUtl  Nn-rc  I 

I'>eri-I)eri.     See  JVrnri/li*,  A/uf/iji/r  Enihmic. 
Bichloride  of  mercury.     See  Mrrrunj. 
Bilateral  athetosis,  709 


Bilharzia  luvniatobia,  9 
Bilious   intermittent   fever.     See   Malarial 
Fevers,  Intermittent. 
remittent  fever.     See  Malarial  Fevers, 

Remittent. 
form  of  typhoid  fever.  102 
Birth-palsies,  706 
Bismuth  in  influenza,  195 
in  measles,  252 
in  relapsing  fever,  161 
in  scarlatina.  228 
in  typhoid  fever,  12S,  129,  132 
Black  leg,  cause  of,  12 
Blacksuiiths,  mortality  of,  26 
lUack  vomit,  456 

Bladder,  abscess  of,  in  typhoid  fever,  93 
attention  to,  in  myelitis,  758 
distension  of,  in  typhoid  fever,  89 
intiammation  of,  in  locomotor  ataxia, 
788 
in  acute  myelitis,  758 
in  chronic  myelitis,  760 
in  typhoid  fever,  ^^^ 
paralvsis  of     See  Sphincters,  ParalysU 

o/.' 
Blindness  in  cerebro-spinal  fever,  168,  173 
following  cerebro-spinal  fever,  176 
following  typhoid  fever,  91 
See,  also,  Amb/yopia  and  Amaurosis. 
Blisters  in  cerebro-spinal  fever,  181,  183 

in  typhoid  fever,  128 
Blood,  bacillus  of  influenza  in,  185,  187 
changes  of,  in  anthrax,  480 

in  cerebro-s]>inal  fever,  175 
in  cholera,  440 
in  miliary  fever.  202 
in  scarlatina,  225 
in  se])tica'mia,  325 
in  typhoid  fever,  87 
in  typhus  fever,  137 
examination  of,  in  malarial  fever,  419 
spirillum  of  relapsing  fever  in,  161,  152 
Bloodletting.     See   I'enrsertion. 
Boiieriuakers,  mortality  of,  26 
Boiling  as  a  disinfectant,  17 
Bone-marrow,  changes  in.  in  relapsing  fever, 
154 
tubercles  in,  in  acute  miliary  tubercu- 
losis, 332 
Bones,  atrophv  of,  in  facial   hemiatrophy, 

hypertroi>hv    of    in    acromegaly,    863, 
.S(i4  ■ 

lesions  of,  in  sirofula,  3-10 

in  hereditary  syphilis,  364 
Bookl)inders,  iMortnlily  of,  2<> 
!5orax  in  foot-and-mouth  disease,  522 
Boric  acid  in  scarlatina,  229 

in  tvphoid  fever,  l.'{2 
I'.nvinc  lym])li.  202 
Braciiial  plexus,  Icsidiis  of,  .S41 
Brachycardia.     See  llradyrnrtlia. 
Bradycardia  in  tynlntid  fever,  87 

following  typhns  fever,  142 
Brain,  abscess  ol,  714 

diagnosis  of,  715 


874 


INDEX. 


Brain,  abscess  of,  etiology  of,  714 
morbid  anatomy  of,  715 
symptomatology  of,  715 
in  cerebro-spinal  fever,  167 
following  influenza,  192 
anaemia  of,  677 
atrophy  and  sclerosis  of,  707 
cancer  of,  718 
changes    in,  in    cerebro-spinal    fever, 

167 
cortical  centres  of,  696 
cysts  of,  718 
glioma  of,  717 
hypersemia  of,  676 
inflammation  of,  714 
lesions  of,  in  hereditary  syphilis,  364 
murmur  in  cerebral  aneurism,  693 

in  hydrocephalus,  724 
oedema  of,  678 

in  erysipelas,  398 
organic  diseases  of,  669 
porencephalus  of,  707 
sarcoma  of,  717 
sclerosis  of,  diffuse,  713 
insular,  711 
miliary,  713 
tuberous,  713 
softening  of,  552 

red,  yellow,  and  white,  689 
syphilis  of.     See  Syphilis  of  Brain. 
syphiloma  of,  717 

tubercle  (tyroma)  of,  717  * 

tumors  of,  717 

diagnosis  of,  722 
prognosis  of,  723 
symptoms,  general  and  focal,  718, 

719 
topographical  diagnosis  of,  719 
treatment  of.  medical  and  surgical, 
723 
Brand   method,  mortality  after  treatment 
by,  111 
in  treatment  of  typhoid  fever,  119 
of  typhus  fever,  148 
Breakbone  fever,  197 
Breathing  in  laryngeal  diphtheria,  382 

in  hereditary  syphilis,  365 
Brewers,  mortality  of,  26 
Bright's  disease.    See  Kidneys  and  Nephritis. 
Bromides  in  cerebro-spinal  fever,  183 
in  convulsions,  627 
in  deliriuni  tremens,  560 
in  dengue,  200 
in  epilepsy,  625 
in  measles,  252 
in  migraine,  659 
in  relapsing  fever,  161 
in  typhoid  fever,  127 
in  whooping  cough,  321 
Bromism,  625 

Bromoform  in  whooping  cough,  321 
Bronchitis  in  actinomycosis,  476 
in  cerebro-spinal  fever,  166,  176 
in  influenza,  189,  194 
in  measles,  238,  246 
in  relapsing  fever,  155 


Bronchitis  in  rubella,  258 

in  scrofula,  340 

in  small-pox,  277 

in  acute  miliary  tuberculosis,  333 

in  typhoid  fever,  66,  88,  95,  98,  132 

in  typhus  fever,  142,  144 

in  whooping  cough,  317 
Bronchitis,  diagnosis  of,  from  acute  miliary 

tuberculosis,  334 
Bronchitis,      chronic,      osteo-arthropathie 

pneumique  in,  864 
"  Bronze  liver,"  423 
Broths.     See  Diet. 
Bubo,  parotid,  309 
Buboes  in  typhus  fever,  145 
Bubonic  plague,  diagnosis  of  from  typhus 

fever,  147 
Builders,  mortality  of,  26 
Bulbar  paralysis,  803 
Bullse  in  anaesthetic  leprosy,  371 

in  erysipelas,  399 
Butchers,  mortality  of,  26 

CAB-DRIVERS,  mortality  of,  26 
Cabinetmakers,  mortality  of,  26 
Cachexia,  malarial,  432 

syphilitic,  353 
Caffeine  in  diphtheria,  395 

in  typhoid  fever,  132 
Caisson  disease,  650 

Calabar  bean  in  cerebro-spinal  fever,  183 
Calcification  of  muscles,  851 
Calm  stage  in  yellow  fever,  455 
Calomel  in  delirium  tremens,  560 
in  influenza, 194 
in  malarial  fever,  421 
in  acute  spinal  meningitis,  742 
in  milk  sickness,  206 
in  acute  poliomyelitis,  769 
in  relapsing  fever,  161 
in  trichinosis,  511 
in  typhoid  fever,  125, 127, 128,  130 
in  typhus  fever,  149 
Camphor  in  typhoid  fever,  127 

in  typhus  fever,  149 
Calor  mordax  in  scarlatina,  215 

in  typhus  fever,  143 
Cancer  of  brain,  718 
Cancrum  oris  in  typhoid  fever,  91 

tumors  of,  721 
Cannabis   Indica   in   cerebro-spinal   fever, 
183 

in  migraine,  659 
in  typhus  fever,  149 
Capsule,  internal,  lesions'of,  700 
Carbolic  acid  in  anthrax,  483 
in  milk  sickness,  206 
in  scarlatina,  229 
in  tetanus,  470 
in  typhoid  fever,  125,  127 
Carbonated  water  in  typhoid  fever,  116 
Carbonic  acid,  proportions  of,  in  air,  38 

in  soil  air,  28 
Carbuncle,    diagnosis    of,    from    anthrax, 

482 
Carbuncles,  metastatic,  in  anthrax,  481 


INDEX. 


875 


Cardiac  crises  in  glosso-lubial  paralysis,  804 
in  locomotor  ataxia,  771* 

diagnosis  of,  from  angina 
pectoris,  785 
embolism,  in  typlioid  fever,  93,  110 
epilepsy.     See  Ep'depxij. 
failure  in  relapsing  fever,  157 
in  typhoid  fever,  110,  182 
paralysis  in  diphtheria,  884 
Cardinal's  case  (hydrocephalus),  724 
Caries  of  bones  in  acquired  syphilis,  352 
Carotid  artery,  ligation  and  compression  of, 
in  cerebral  luemorrhage,  092 
internal,  symptoms  following  oc- 
clusion of,  691 
Carpenters,  mortality  of,  26 
Carphalogia  in  acute  miliarv  tuberculosis, 
332 
in  typhoid  fever,  81,  113 
Castor  oil  in  typhoid  fever,  130 
Catalepsy  in  hysteria,  598 
Catarrhal  symptoms  of  measles,  238 
Catheterization  in  hysteria,  609 
in  locomotor  ataxia,  788 
in  acute  myelitis,  758 
in  typhoid  fever,  89 
Cauda  equina,  disturbances  caused  by  pres- 
sure upon, 849 
Cemeteries,  legislation  regarding,  42 
Centrum  ovale,  lesions  of,  700 
Cephalalgia.     See  Headache. 
Cerebellar  ataxia,  722 

vertigo,  722 
Cerebellum,  tumors  of,  722 
Cerebral  ansemia,  677 

symptoms  and  treatment  of,  678 
arteries,  aneurism  of,  (593 
embolism.     See  Embolism  and  Throm- 
bose. 
Cerebral  contractures,  diagnosis   of,    from 

spinal  contractures,  792 
Cerebral  hamiorrhage,  679 

conjugate  deviation  in,  685 
convulsions  in,  682 
crossed  hemiplegia  in,  6X4 
diagnosis  of.  686 
etioliigy  of,  679 
hemiaruesthesia  in,  685 
hemiplegia  following,  683 
locations  of,  680 
morbid  anatomy  of,  680 
prognosis  of,  687 
secondary  symptoms  of,  685 
.symptoms  of,  6X2 
treatment  of,  (Jttl 
Cerebral    hemorrhage,  diagnosis   of,  from 
acute  alcoholism,  686 
frf)m  epilepsy,  686 
I'rotii  opium-poisoning,  686 
Cerebral  liyperaMiii;!.  676 

forms,  morl)id  anatomy,  and  symp- 
toins  of,  677 
localization,  696 
thrombosis.    Sec  Embollum  and  Throm- 

bOMlK. 

Cerebritis.     See  Encephalitix. 


Cerebro-spinal  fever,  162 

clinical  description  of,  167 
complications  of,  176 
definition  of,  162 
diagnosis  of,  177 
duration  of,  179 
etiology  of,  164 
history  of,  162 
morl)id  anatomy  of,  166 
mortality  of,  179 
prognosis  of,  179 
relapses  in,  177 
sequela^  of,  176 
synonyms  ot",  162 
treatnient  of,  180 
Cerebro-spinal  fever,  diagnosis  of,  from  in- 
fluenza, 178,  193 
from  malarial  lever,  179 
from  meningitis,  179 
from  rheumatic  fever,  179 
from  scarlatina,  179 
from  sniall-pox,  179 
from   tuberculous  meninsritis, 

177 
from  typhoid  fever,  106.  178 
from  typhus  fever,  146,  178 
Cerebro-spinal  form  of  typhoid  fever,  82, 
102 
of  typhus  fever,  144 
Cerium  oxalate  in  iiiflueii/.a,  195 
Cervical  pachymeningitis,  743 

plexus,  affections  of,  840 
Champagne  in  tvjihoid  fever,  116,  128 
Chancre,  348 
Character,  significance  of  changes  in  the, 

542 
Charcot's  joints,  782 

Charcot-Marie   type   of   progressive   myo- 
pathic atrophy,  852 
Chemical  disinfectants,  19 
Cheyne-Stokes  respiration  in  cerebral  luem- 
orrhage, 682 

in  cerebnil  tumor,  719 

in  cerel)ro-siiinal  lever,  175 

in  hiematuric   intermittent    fever, 

427 
in  tuberculous  meningitis,  672 
Chiasma  and  tract,  lesions  of,  816 
Chicken-pox.     v^ee  Varicrlla. 
Children,  fatality  of  small-pox  in,  280 
typlioid  fever  in,  103 
typhus  fever  in,  145 
Chills,  occurrence  of,  in  anthrax,  481 
in  bilious  intermittent  fever,  427 
in  ctTcbro-spinal  fever,  168 
in  dengue,  198 
in  (li])iitiieriji,  381 
in  erysipelas,  399 
in  foot-aMd-niouth  disease,  521 
in  glanders,  513 
in   luematnric  pernicious    inliiniittent 

fever,  427 
in  liM'inoglobinuria,  Xfil 
in  iMlliienza,  1^7 
in  intermittent  i'evir,   ll.'} 
in  measles.  23K 


876 


INDEX. 


Chills  in  mountain  fever,  207 

in  multiple  neuritis,  807 

in  mumps,  307 

in  pyaemia,  327 

in  rubella,  256 

in  scarlatina,  214 

in  septicaemia,  325 

in  small-pox,  266 

in  acute  spinal  meningitis,  742 

in  syphilis,  352 

in  acute  miliary  tuberculosis,  332 

in  typhoid  fever,  68 

in  typho-malarial  fever,  431 

in  typhus  fever,  138 

in  yellow  fever,  455 
Chills  and  fever.     See  Malarial  Fevers. 
Chin  reflex,  525 

in  spastic  bulbar  paralysis,  795 
Chloral  in  cerebro-spinal  fever,  183 

in  delirium  tremens,  561 

in  simple  insomnia,  661 

in  measles,  252 

in  melancholia,  567 

in  relapsing  fever,  161 

in  scarlatina,  228,  229 

in  small-pox,  282 

in  St.  Vitus's  dance,  632 

in  tetanus,  470 

in  typhoid  fever,  127 

in  typhus  fever,  149 

in  whooping  cougli,  321 
Chloride  of  iron  in  diphtheria,  392,  395 
in  erysipelas,  403 
in  brain  syphilis,  732 
in  typhoid  fever,  131 

of  lime  as  a  disinfectant,  20 

of  zinc  as  a  germicide,  20 
Chlorine  as  a  disinfectant,  19 
Chlorine-water  in  typhoid  fever,  125,  127 

in  typhus  fever,  149 
Chloroform  in  cerebro-spinal  fever,  183 

in  relapsing  fever,  161 

in  yellow  fever,  4()1 
Chloroform  liniment  in  multiple  neuritis, 
816 

in  typhoid  fever,  127 
Chlorosis  following  typhoid  fever,  95 
Choked  disk,  816 
Cholera,  434 

age,  race,  and  sex  in  etiology  of,  436 

bacillus  of,  436 

cause  of,  12,  436 

of  symptoms  in,  438 

climate  and  season  in  etiology  of,  435 

complications  and  sequelae  of,  444 

definition  of,  434 

diagnosis  of,  445  ,  , 

disinfection  after,  449 

duration  of,  445 

recent  epidemics  of,  434 

etiology  of,  435 

morbid  anatomy  of,  439 

mortality  and  prognosis  of,  446 

period  of  incubation  in,  440 

prophylaxis  of,  446 

quarantine  against,  450 


Cholera,  relation  of,  to  miliary  fever,  201 
rigor  mortis  in,  439 


sicca,  442 


stages  of,  440 

stools,  cholera  bacillus  in,  441 

micro-organisms  in,  441 
symptomatology  of,  440 
synonyms  of,  434 
treatment  of,  446 

of  convalescence  from,  449 
Cholera,  diagnosis  of,  from  acute  mineral 
poisoning,  445 
from  cholera  morbus,  445 
from  malarial  fever,  429 
from  trichinosis,  509 
from  typhoid  fever,  445 
Cholera  bacillus,  12,  436 

cultivation  of,  437 
in  soil,  29 
in  water,  30 
Cholera  infantum,  cause  of,  12 
morbus,  cause  of,  12 

diagnosis  of,  from  cholera,  445 
Cholerine,  434 
Chorea,  526 

general,  526 
habit,  634 
local,  526 
senile,  634 

following  typhoid  fever,  91 
See,  also,  Aafomafic,   Convulsive,  Heredi- 
tary,  and    Reflex    Chorea,    St.     Vitus's 
Dance,  and  footnote,  p.  627 
Choreic  movements,  causes  of,  526 

definition  of,  526 
Choreiform    movements    in    cerebro-spinal 
fever,  173 
in  cerebral  haemorrhage,  682 
Choroid,  tubercles  in  the,  in  tuberculous 
meningitis,  673 
in  acute  miliary  tuberculosis,  332 
plexuses,  sclerosis  of,  724 
Chronic  periencephalitis.    See  Periencepha- 
litis, Chronic. 
Cimicifuga  in  St.  Vitus's  dance,  633 
Circular  insanity,  586 
Circulation,  effect  of  exercise  upon  the,  23 
Circumcision,  tuberculous  infection  in  do- 
ing, 329 
Circumflex  nerve,  affections  of,  843 
Clavus,  65(') 
Claw-hand  in  muscular  atrophy,  8.56 

in  progressive  muscular  atrophy,  801 
Clergymen,  mortality  of,  26 
Clerks,  mortality  of,  26 
Climate  in  etiology  of  dengue,  197 

of  malarial  fevers,  410 
Clothing,  24 

color  of,  25 
disinfection  of,  17 
infection  through,  25 
Cocaine  in  cholera,  447 
in  influenza,  195 
in  sciatica,  849 
in  whooping  cough,  322 
Coccydynia,  847 


I 


INDEX. 


877 


Codeine  in  dengue.  200 
in  influenza,  195 
in  typhoid  fever,  127,  128 
Cod-liver  oil  in  scrofula,  84o 

iifter  typhoid  fever,  133 
Coffee-ground  vomit  in  locomotor  ataxia, 

779 
Cold  in  hyperpyrexia,  118 

etfect  of,  on  poison  of  scarlatinu,  213 
on  poison  of  yellow  fever,  452 
pack,  application  of,  US 
Colic  in  Raynaud's  disease,  8(31 
Collapse  in  relapsing  fever.  158 
in  typhoid  fever,  87,  110 
stage  of,  in  cholera,  442 
Colles's  law,  361 
Coma,  definition  of,  659 
Coma  in  cerebral  abscess,  715 

embolism  and  thrombosis,  690 
haemorrhage,  682 
syphilis,  72(),  728 
sinus  thrombosis,  694 
tumor,  719 
in  cerebro-spinal  fever.  172 
in  erysipelas,  400 
in  measles,  244 

in  pernicious  malarial  fever,  428 
in  Raynaud's  disease,  861 
in  scarlatina,  219,  222 
in  small-j)0x,  267 
in  thermic  fever,  646 
in  acute  miliary  tuberculosis,  834 
in  tuberculous  meningitis,  672 
in  typhoid  fever,  80 
Coma  vigil  in  typhoid  fever,  80,  113 
Comatose  form  of  malarial  fever,  428 
Comma  bacillus,  436 
Commercial  travellers,  mortality  of,  26 
Complicating  insanities,  546 
Comj)ression  of  spinal  cord,  atrophy  from, 

852 
Concussion  of  spinal  cord,  744 
Confluent  small-pox,  273 
Confusional  insanity,  570 
definition  of,  570 
diagnosis  and  prognosis  of,  573 
etiology  of,  570 
symptom.atology  of,  570 
synonyms  of,  570 
treatment  of,  573 
follcnving  typhoid  fever,  90 
Congenital  paramyotone,  857 

syjihilis.     See  Siiphitix,  Ifireditunj. 
Conjugate   deviation    in    c(rel)ral    lueuior- 
rhage,  685 

tumor,  721 
in  tu"l)ercuh)us  meningitis,  673 
Conjun(;tivitis  in  m<asles,  247 
Consciousness,  double,  667 

doiible     personality    in     disorders    of, 

6«;7 

and   memory,  correlated   disorders  of, 
664 
Constipation  in  hysteria,  602 

in  typhoid  f(;ver,  68,  83 
Constitutional  insanities,  557 


Contagious  diseases,  disposal  of  body  after 
death  from,  43 
hospitals  for,  21 
Continued  thermic  fever,  646 
Contractures,  ilefinition  of,  525 
in  antero-lateral  sclerosis,  790 
in  cerebral  palsies  of  children,  707,  709, 

710 
diagnosis  of  sj)inal  from  hvsterical,  603, 

792 
in  Friedreich's  ataxia,  798 
in  hemiplegia,  685 
in  hysteria,  603 

following  acute  poliomyelitis,  766 
in  progressive  muscular  atrophy,  801 
in  pseudo-muscular  hypertrophy,  854 
in  chronic  spinal  meningitis.  743 
Convalescence  of  typhoid  lever,  69 
management  of,  in  cholera,  449 
in  diphtheria,  396 
in  typhoid  fever,  133 
Convulsions,  626 

epileptiform,  626 
hysterical,  626 
tetanic,  626 
treatnient  of,  627 
types  of,  524,  626 
Convulsions  in  cerebral  haemorrhage,  682 
syi)hilis,  729 
tumor,  719 
in  cerebro-spinal  fever,  168,  173 
in  dengue,  198 
in  epilei>sy,  612 
in  hysteria,  596 
in  infantile  hemiplegia,  707 
in  malarial  fever,  414 
in  measles,  244 
in  miliary  fever.  202 
in  milk  sickness,  2<i5 
in  multiple  alcoholic  neuritis,  808 
in  chronic  perienceidialitis,  554 
in  acute  polinmyelitis,  763 
in  relapsing  lever,  155 
in  scarlatina,  215,  228 
in  small-pox,  267 
in  strychnine-poisoning,  diagnosis    of, 

li-oni  tetanus,  468,  626 
in  tetainis,  467 
in  thermic  fever,  646 
in  typhoid  fever,  81 
in  typhus  fever,  14(1 
Convulsive  chorea,  633 
clioreic  tic,  634 
definition  of.  633 
hysterical,  634 
organic,  (i34 
Convulsive  tic,  K32 
Cooking,  importance  of,  "22 
Co-ordination,  527 

disturbance  of.  in  diphtheritic  paraly- 
sis, 3K1 
in  IncoMHilnr  ataxia,  7S0 
in  chroMic  prricMccphalitis,  553 
Coprolalgia,  636 

Cornea,  indammaticn  of  in  cerebro-spinal 
fev<T.  173 


878 


INDEX. 


Cornea  in  hereditary  syphilis,  364 

in  typlioid  fever,  91 
Corpora  quadrigemina,  lesions  of,  700 

<     tumors  of,  721 
Corpus  striatum,  tumors  of,  721 
Corrosive  sublimate  as  a  disinfectant,  20. 

See,  also,  Mercury. 
Corymbose  eruption  in  small-pox,  275 
Coryza  in  influenza,  188 

in  iodism,  8")9 

in  measles,  238 

in  rubella,  250 

in  scrofula,  340 

in  whoopiufj;  cough,  314 
Costermongers,  mortality  of,  26 
Cotton-manutiutturers,  mortality  of,  26 
Cough  in  laryngeal  diphtheria,  382 

in  measles,  239,  246 

in  acute  miliary  tuberculosis,  333 

in  typhoid  fever,  88 

in  whooping  cough,  315 
Counter-irritants  in  cervical  pachymenin- 
gitis, 743 

in  facial  paralysis,  831 

in  influenza,  195 

in  locomotor  ataxia,  787 

in  meningitis,  676 

in  multiple  neuritis,  811 

in  acute  myelitis,  757 

in  chronic  myelitis,  760 

in  acute  poliomyelitis,  769 

in  sciatica,  849 

in  acute  spinal  meningitis,  742 

in  chronic  spinal  meningitis,  743 

in  syringomyelia,  775 
Coup  de  soleil.     See  Thermic  Fever. 
Cow-pox,  283 

eruption  in,  286 
period  of  incubation  in,  286 
Cramps  in  cholera,  442 
Cranial  reflexes,  525 
Craniotabes  in  hereditary  syphilis,  364 
Creasote  in  scrofula,  343 

in  typhoid  fever,  128 
Cremaster  reflex,  524 
Cremation,  16 

of  garbage,  16 
Crescentic  forms  in  blood  of  malarial  sub- 
jects, 408 
Crises  in  locomotor  ataxia,  778 

cardiac  in  glosso-labial  paralysis,  804 
Crisis,  occurrence  of,  in  dengue,  198 

in  measles,  238,  242 

in  relapsing  fever,  155 

in  typhoid  fever,  99 

in  typhus  fever,  141 
Crossed    hemiplegia   in    cerebral    haemor- 
rhage, 684   . 
Cross-legged  progression   in  infantile  spas- 
tic paraplegia,  710 
Croup,    membranous,    diagnosis   of,    from 
dijjhtheria,  386 

relation  of,  to  diphtheria,  376,  386 
Crus  cerebri,  lesions  of,  701 
Crutch-palsy,  843 
Cruveilhier's  paralysis,  799 


Cry  in  hereditary  syphilis,  365 
Cupping  in  cerebro-spinal  fever,  181 
in  influenza,  196 
in  typhoid  fever,  132 
in  typhus  fever,  149 
Cutters,  mortality  of,  26 
Cyanosis  in  acute  miliary  tuberculosis,  334 
Cyclothymia,  586 
Cystitis  in  locomotor  ataxia,  788 
in  acute  myelitis,  758 
in  chronic  myelitis,  760 
in  typhoid  fever,  66,  97 
Cysts  of  brain,  718 

following  haemorrhage,  681 
in  chronic  periencephalitis,  558 
porencephalic,  707 
thrombotic,  689 

DEAD,  disposal  of  the,  42 
bodies,  disinfection  of,  21 
Deafness  in  acromegaly,  864 

in  brain  tumor,  721 

in  cerebro-spinal  fever,  174,  176 

in  hysteria,  605 

in  locomotor  ataxia,  782 

in  scarlatina,  218 

following  scarlatina,  223 
small-pox,  277 

in  typhoid  fever,  80 

following  typhus  fever,  145 
Deafness,  nervous,  834 
causes  of,  834 
Death,  sudden,  in  cholera,  443 
Death-i-ates,  average,  5 

of  different  occupations,  25 
Decubitus  in  typlioid  fever,  69 

in  typhus  fever,  138 
Deep  reflexes,  525 
Degeneration,  reaction  of.     See  Reaction  of 

Degeneration. 
Deglutition,  diflicult.     See  Dysphagia. 
Delayed  sensation  in  locomotor  ataxia,  780 
Delhi  boil,  cause  of,  12 
Delirium  in  cerebro-spinal  fever,  172 

in  delirium  tremens,  559 

in  dengue,  198 

in  erysipelas,  400 

in  hydrophobia,  493 

in  influenza,  189 

in  measles,  243 

in  simple  meningitis,  674 

in  acute  periencephalitis,  549 

in  relapsing  fever,  156 

in  scarhitina,  215 

in  acute  miliary  tuberculosis,  332,  333 

in  typhoid  fever  79 

in  typhus  fever,  140 
Delirium  cordis  in  typhoid  fever,  110 
Delirium  tremens,  559 

diagnosis  of,  560 
treatment  of,  560 
Deltoid  muscle,  atrophy  of,  in  circumflex 

paralysis,  843 
Delusions,  535 

in  alcoholic  insanity,  562 

classification  of.  537 


INDEX, 


879 


Delusions,  expansive,  537 

of  grandeur,  aS? 

hypochondriacal,  537 

in  melancholia,  563 

in  paranoia,  581 

in  chronic  periencephalitis,  552 

of  persecution,  538 

sources  of,  536 

systematized,  53S 

in  typhoid  fever,  79 

unsystematized,  538 
Dementia  in  epilepsy,  618 

in  St.  Vitus's  dance,  630 
Dengue,  197 

complications  of,  199 

definition  of,  197 

diagnosis  of,  199 

duration  of,  198 

etiology  of,  197 

morbid  anatomy  of,  198 

prognosis  of,  199 

sequela?  of,  199 

symptomatology  of,  198 

synonyms  of,  197 

treatment  of,  199 
Dengue,  diagnosis  of,  from  influenza,  199 
from  rheumatic  fever,  199 
from  yellow  fever,  199 
Dentition  in  hereditary  syphilis,  364 
Deodorants,  16 

Deodorizing  by  sulphate  of  iron,  20 
Desiccation  in  small-pox,  269 
Desires,  morbid,  542 
Desquamation  in  dengue,  198 

in  erysipelas,  399 

in  measles,  241 

in  rubella,  258 

in  scarlatina,  216 

in  typhoid  fever,  72 

in  typhus  fever,  144 
Deviation,  secondary,  in  ocular  paralysis, 

822 
Diabetes  mellitus  in  brain  syphilis,  729 
in  Jews,  8 

following  relapsing  fever,  159 
following  typhoid  fever,  97 
Diaphragm,  degeneration  of  muscle  of,  841 

paralysis  of,  840 

in  acute  ascending  paralysis,  749 

spasm  of,  841 
Diaphyso-epiphyseal  separation  in  heredi- 
tary syi)liilis,  364 
Diarrhn?a  in  angio-neurotic  redema,  862 

in  anthrax,  481 

in  cerebro-spinal  fever,  176 

in  cholera,  440 

in  glanders,  515 

in  influenza,  188 

in  mercuriaiism,  358 

in  pya-iiiiii,  307 

in  Raynaud's  disease,  861 

in  relapsing  fever,  158 

in  scrfjfula,  341 

in  thermic  fever,  646 

in  trichinosis,  505,  506 

in  typhoid  fever,  68,  83,  129 


Diarrhoea  in  typhus  fever,  144 
Diathesis,  scrofulous,  336 
Diazo-reaction  in  measles,  89 

in  tul)erculosis,  108 

iti  typhoid  fever,  89 
Dicrotism  of  pulse  in  typhoid  fever,  87 

in  typhus  fever,  142 
Diet  in  cerebro-spinal  fever,  180 

in  confusional  insanity,  574 

in  (li'lirium  tremens,  560 

in  diphtheria,  395 

in  epilepsy,  624 

in  erysipelas,  403 

in  iiiflnenza,  194 

in  miliary  fever,  203 

in  neurasthenia,  590 

in  pernicious  intermittent  fever,  430 

in  relapsing  fever,  160 

in  scarlatina,  227 

in  scrofula,  343 

in  small-jiox,  281 

in  tetanus,  469 

in  typhoid  fever,  115 

in  typhus  fever,  148 

in  yellow  fever,  46 
Difl["use  muscular  atrophies,  852 
Digitalis  in  cerebro-spinal  fever,  183 

in  delirium  tremens,  561 

in  diphtheria,  395 

in  influenza,  195 

in  relapsing  fever,  161 

in  typhoid  fever,  124,  131 

in  typhus  fever,  149 
Dilatation  of  heart  in  typhoid  fever,  93 
Diphtheria,  373 

in  aninuils,  375 

associated  diseases  in,  378 

bacillus  of,  374 

cardiac  ])aralysis  in,  384 

cause  of,  11,  373 

complications  and  sequela?  of,  385 

contagiousness  of,  377 

definition  of,  373 

diagnosis  of,  386 

duration  and  terminations  of,  385 

etiology  of,  373 

immunity  from,  in  animals,  375 

mode  of  infection  in.  377 

inoculation  experiments  in,  375 

intubation  in,  393 

invasion  in,  381 

isolation  in,  388 

of  larynx,  382 

local  applications  in,  389 

malignant  types  of,  384 

morbid  anatomy  of,  379 

mortal itv  of,  388 

of  nares,  382 

paralysis  in,  384 

period  of  incubation  in,  381 

prognosis  of,  ,3K7 

prophylaxis  of,  388 

jiseiido-diplitheritic  processes  in,  376 

ptomaines  in,  375 

relations  of,  to  membranous  croup,  376, 
3X(; 


880 


INDEX. 


Diphtheria,  relations  of,  to  scarlatina,  214, 
220 
symptomatology  of,  381 
synonyms  of,  373 
tracheotomy  in,  393 
treatment  of,  388 
Diphtheria,  diagnosis  of,  from  erysipelas, 
387 
from  membranous  croup,  38G 
from  scarlatina,  222,  387 
from  tonsillitis,  386 
Diphtheria  bacillus,  11,  373 

attenuated,  immunity  conferred  by 

inoculation  of,  375 
results  of  inoculation  of,  374 
in  soil,  29 
Diphtheritic  inflammation,  379 

membrane,  histology  of,  379 
Diplegia,  spastic,  708 

bilateral  athetosis  in,  709 
morbid  anatomy  of,  709 
symptoms  of,  709 
Diplococci  in  lungs  in  measles,  236 
Diplococcus  pneumoniae,  11 
Diplopia,  823 

in  cerebro-spinal  fever,  168 
in  locomotor  ataxia,  781 
early,  in  locomotor  ataxia,  785 
in  typhoid  fever,  80 
Dipsomania,  585 
Discrete  small-pox,  270 
Disease,  classification  of,  3 
mental  causes  of,  8 
predisposing  causes  of,  7 
Diseases  due  to  dust,  26 

to  micro-organisms,  9 
to  improper  ventilation,  37 
functional,  of  the  nervous  system,  587 
mental,  529 

organic,  of  the  brain,  669 
of  the  spinal  cord,  737 
Disinfectants,  chemical,  19 
Disinfection,  15 
by  boiling,  17 
by  chloride  of  lime,  20 
by  chlorine,  19 
by  corrosive  sublimate,  20 
by  cremation,  16 
by  heat,  16 

by  hydrochloric  acid,  20 
by  sulphuric  acid,  20 
by  sulphurous  acid,  19 
by  superheated  steam,  17 
in  cholera,  449 
in  diphtheria,  889,  396 
in  erysipelas,  402 
in  scarlatina,  226 
in  small-pox,  280 
in  typhoid  fever,  113 
of  discharges  in  typhoid  fever,  113 
of  rooms,  19 
public  stations  of,  18 
Disposal  of  the  dead,  42 
Disseminated   sclerosis.     See  Insular  Scle- 
rosis. 
Diver's  paralysis,  650 


Dorsal  nerves,  affections  of,  845 
Double  consciousness,  667 

personality,  667 
Doubting  insanity,  578 
Drainage,  defective,  in  etiology  of  cholera, 

436 
Drapers,  mortality  of,  26 
Dropsy.     See  (Edema. 

Drug  eruptions,  diagnosis  of,  from  measles, 
250 

from  rubella,  209 
from  scarlatina,  222 
Duchenne  type  of  muscular  atrophy,  854 

of  anterior  poliomyelitis,  852 
Dumb  ague,  417 

Duodenum,  enanthem  of  measles  in,  241 
Dura  mater,  diseases  of,  669 
Dust,  diseases  produced  by,  26 
Dysacusis,  833 
Dysentery,  cause  of,  12 

in  typhoid  fever,  92 
Dysphagia  in  cerebro-spinal  fever,  172 

in  glosso-labial  paralysis,  804 

in  hydrophobia,  493 

in  hysteria,  602 

in  scarlatina,  217 

in  tetanus,  467 

in  trichinosis,  506 

in  typhoid  fever,  91 

in  typhus  fever,  140 
Dvspnrea   in    acute    ascending    paralysis, 
749 

in  anthrax,  481 

in  bilateral  abductor  paralysis,  836 

in  cholera,  443 

in  diphtheria,  382,  383 

in  glosso-labial  paralysis,  804 

in  hysteVia,  602 

in  small-pox,  266 

in  tetanus,  467 

in  tetany,  638 

in  trichinosis,  506 

in  acute  miliary  tuberculosis,  333 

EAR,  affections  of,  in  measles,  248 
in  scarlatina,  217,  223 
involvement  of,  in  small-pox,  277 
in  hereditary  syphilis,  363 
Earthenware-makers,  mortality  of,  26 
Eberth's  bacillus,  55 
Ecchymoses  in  tvphus  fever,  144 
Eclio'lalgia,  636  ' 
Electrical  reactions.     See  Reaction  of  De- 

genernfion  and  Reactions. 
Electricity  in  facial  paralysis,  831 

in    idiopathic    muscular   atrophv, 

856 
in  locomotor  ataxia,  788 
in  neuralgia  of  fifth  nerve,  827 
in  neurasthenia,  591 
in  paramyoclonus  multiplex,  858 
in  acute  poliomyelitis,  769.  770 
in  scleroderma,  866 
in  torticollis,  839 
Elephantiasis  following  erysipelas,  401 
Emaciation  in  anorexia  nervosa,  605 


lyDKX. 


881 


Emaciation  in  cholera,  442 
in  pytemia,  327 
in  typhoid  fever,  70 
Embalming,  42 

Embolism  and  thrombosis  of  cerebral  arte 
ries,  G88 

anatomical    changes    in 

689 
etiology  of,  688 
symptoms  of,  690 
treatment  of,  691 
Embolism  and  thrombosis  of  special  cere- 
bral arteries,  691 
Emetics  in  ty])hoid  fever,  128 
Emotional   nature,  general   considerations 

on  the,  580 
Emphysema  in  whooping  cough,  317 

influence  of,  in  typhoid  fever,  112 
Emprosthotonos  in  tetanus,  467 
Empysema  in  influenza,  190 
typhoid  bacillus  iu,  56 
Enanthem  of  measles,  238,  239 
Encephalitis,  suppurative,  714 
Encephalopathies  in  syphilis,  353 
Endarteritis  in  etiology  of  cerebral  ha?mor- 
rhage,  680 
in  tyi)hoid  fever,  65 
Endemic  neuritis.     See  Neuritis,  Multiple, 

Endemic. 
Endocarditis  in  cerebro-spinal  fever,  176 
in  diphtheria,  385 
in  scarlatina,  225 
in  St.  Vitus's  dance,  631 
in  tyj)h()id  fever,  93 
Endocarditis,  acute  ulcerative,  diagnosis  of, 

from  malarial  fever,  429 
Endocardium,  tubercles  in,  in  acute  miliary 

tuberculosis,  331 
Enemata  in  milk  sickness,  206 
in  typhoid  fever,  130 
in  typhus  fever,  149 
Engineers,  mortality  of,  26 
Enteric  fever.     See  Tupltoid  Fever. 
i^nteroclysis  in  cholera,  448 
Enterorrhagia  in  dengue,  198 
in  influenza,  190 
in  rela[)siiig  fever,  158 
in  typhoid  fever,  78,  92 
in  typhus  fever,  144 
Ephemeral  fever,  46 
cause  of,  46 
diagnosis  of,  48 
history  of,  46 
pathology  of,  50 
prognosis  of,  50 
symptomatology  of,  47 
treatment  of,  50 
Ephemeral  fever, diagnosi.s  of,  from  malarial 
fever,  49 
from  typhoid  fever,  49,  107 
Epidemicr  cerebro-spinal  meningitis.      See 

derehro-njiuKil  Fever. 
E|)idemics,  iimiiunity  (hiring,  13 
of  cereljro-sitiiial  fever,  163 
of  typhoid  fever,  59 
Epigastric  rcHex,  525 
Vol,.  I.— 66 


Epilepsia  procursiva,  616 
Epilepsy,  612 

age  and  sex  in  etiology  of,  612 

aura  in,  614 

cardiac,  svncopal  and  congestive  types 
of,  618  ' 

convulsion  in,  612 

definition  of,  612 

dementia  in.  618 

diagnosis  of,  618 

etiology  of,  612 

in  infantile  hemiplegia,  708 

Jacksonian,  618,  673,  719 

nocturnal,  616 

organic,  ()20 

pathology  of.  ()21 

prognosis  of,  621 

pupils  in  the  i)aroxysm  of,  613 

reflex,  620 

spinal,  791 

symptonuitology  of,  612 

synonyms  of.  612 

temperature  in,  614 

toxa^mic,  620 

treatment  of,  622 
Epilepsy,  diagnosis  of,  from  cerebral  luem- 
orrhage,  686 
from  hysteria,  619 
Epileptic  automatism,  613,  615 

cry,  614 

mania,  617 

seizures,  in  Raynaud's  disease,  861 
Epileptiform  convulsions,  (526 

in  cerebral  luemorrhage,  682 
in  cerebral  syphilis,  726 

tumor,  71!' 
in  chronic  periencephalitis,  554 
Epiphyso-diapliyseal  separation  in  heredi- 
tary sypjiilis.  3()4 
Epistaxis  in  high  altitudes,  207 

in  diphtheria,  382 

in  ephemeral  fever,  48 

in  influenza.  189 

in  measles,  244 

in  mountain  fever,  207 

in  rela|ising  fever.  155 

in  typhoid  fever.  SO,  131 

ill  typhus  fever.  138 

treatment  of,  liil 
Erb  type  of  anterior  poliomyelitis,  852 

of  jirogrcssive  uivop:itliic  atropliv, 
852,  854 
Erector-spinal  reflex,  525 
Erethritic  type  of  scrofula,  340 
Ergot,  in  acute  ascending  paralysis,  751 

in  cerei)ru-spinal  fever.  1S3 

in  hicomotor  ataxia,  787 

in  :i<'u;e  myelitis,  75() 

in  acute  peri«'neeplialitis.  55(» 

in  chronic  iiericncepliaiitis.  556 

in  acute  polinniyclil  is,  76".' 

in  spinal  iiy|>eraiiiia,  74'> 
Ergotin  in  typhoi<l  (ever.  131 
Erig<'rou  in  typhoid  fever,  131 
Erotomania,  ol2 
Erroneous  proji-ctioii  froiri  strabismus,  823 


882 


INDEX. 


Eruptions  in  anthrax,  481 

in  cerebro-spinal  fever,  174 

in  cliolera,  444 

in  cow-pox,  286 

in  dengue,  198 

in  erysipelas,  398 

in  foot-and-nioutli  disease,  521 

in  glanders,  515 

initial,  in  small-pox,  267 

of  iodine,  359 

in  leprosy,  370 

in  measles,  241,  244,  245 

in  miliary  fever,  202 

in  acute  periencephalitis,  549 

in  rubella,  256 

in  scarlatina,  216 

in  small-pox,  268 

in  syphilis,  352 

in  syringomyelia,  774 

in  tertiary  syphilis,  351 

in  trichinosis,  507 

in  acute  miliary  tuberculosis,  332 

in  tuberculous  meningitis,  672 

in  typhoid  fever,  70 

in  typhus  fever,  138,  139 

in  varicella,  299 

in  varioloid,  275 

in  yellow  fever,  456 
Erysipelas,  397 

complications  of,  400 

course  of,  400 

definition  of,  397 

diagnosis  of,  401 

■erratic  or  migrans,  399 

etiology  of,  397 

idiopathic  or  "  medical,"  397 

isolation  in,  402 

morbid  anatomy  of,  398 

prevention  of  spread  of,  402 

prognosis  of,  401 

sequelae  of,  401 

streptococcus  erysipelosus  in,  397 

symptomatalogy  of,  398 

synonyms  of,  397 

traumatic,  397 

treatment  of,  401 
Erysipelas,    diagnosis    of,    from     anthrax, 
482 
from  diphtheria,  387 
Erythema  in  small-pox,  268 

in  typhoid  fever,  72 

diagnosis  of,  from  scarlatina,  222 
Erythromelalgia,  848 

Eschar,  sloughing,  in  cerebral  haemorrhage, 
683 
in  acute  myelitis,  755 
Ether  in  cerebro-spinal  fever,  183 

in  typhoid  fever,  131 
Eucalyptus  in  relapsing  fever,  161 
Eyes,  conjugate  deviation  of,  in  cerebral 
luemorrhage,  685 
in  cerebral  tumor,  721 
in  tuberculous  meningitis,  673 
Exanthem.     See  Enipiinn. 
Exanthematic  typhus,  134 
Exercise,  23 


Exercise,  effect  of,  on  circulation,  23 

in    treatment   of  idiopathic    muscular 

atrophy,  856 
Exhalation,  composition  of,  38 
Expansive  delusions.     See  Delusions. 
Experts,  medical,  function  of,  in  railway 

cases,  644 

FACE,    appearance    of,    in    acromegaly, 
863,  864 

in  cerebro-spinal  fever,  168 
in  hydrocephalus,  724 
iu  hysteria,  599 
in  mumps,  308 
in  myxoedema,  864 
in  osteitis  deformans,  864 
in  paralysis  agitans,  640 
in  relapsing  fever,  155 
in  scleroderma,  865 
in  scrofula,  340 
in  small-pox,  267 
in  hereditary  syphilis,  365 
in  tetanus,  466 
in  typhoid  fever,  69 
in  typhus  fever,  138,  139 
in  yellow  fever,  455 
Facial    asymmetry  in  facial  hemiatrophy, 
866 
in  torticollis,  838 
Facial  hemiatrophy,  852,  866 
Facial  nerve,  paralysis  of,  827 

of  cerebral  origin,  828 
of  nuclear  origin,  828 
of  peripheral  origin,  828 
diagnosis  of,  831 
prognosis  of,  830 
treatment  of,  831 
Facial   paralysis,  diagnosis  of  the  various 

forms  of,  831 
Facial  phenomenon  of  tetany,  639 
Facial  spasm,  832 
Facio-scapulo-humeral   form   of  muscular 

atrophy,  854 
Faecal  vomiting  in  hysteria,  603 
Faeces,  typhoid  bacillus  in,  56 
P^arcy.     See  Glanders. 
Farmers,  mortality  of,  26 
Fear,  morbid,  forms  of,  539 
Febricula,  46 
Febris  recurrens,  150 

Femoral  arterv,   occlusion  of,  in  typhoid 
fever,  93 
vein,  thrombosis  of,  in  typhoid  fever, 
93 
Festination  in  paralysis  agitans,  640 
Fever  in  secondary  syphilis,  352 

intermittent,  in  acute  miliary  tubercu- 
losis, 333 
secondary,  in  small-pox,  272 

in  typhoid  fever,  74. 
susceptibility  to,  46.     See,  also,   Tem- 
peraUire. 
Fibrillary  contractions  in  peroneal  type  of 
muscular  atrophy,  856 

in  progressive  muscular  atrophy, 
800 


INDEX. 


883 


Field  of  vision,  contraction  of,  in  hysteria, 
601 
in  locomotor  ataxia,  782 
FiC'vro  i\  rechutes,  150 
Fifth  nerve,  neuralgia  of,  826 

treatment  of,  827 
Fifth  nerve,  paralysis  of,  824 
diagnosis  of,  825 
gustatory  symptoms  in,  82o 
svmptoms  of,  motor  and  seusorv, 
'  825 

trophic  changes  in,  825 
File-makers,  mortalitv  of,  26 
Filters,  31 

typhoid  bacillus  in,  58 
Fisher's   brain-murmur  in  hvdrocephalus, 

724 
Fishermen,  mortality  of,  26 
Flagellate  forms  in  blood  of  malarial  sub- 
jects, 408 
Flatulence  in  hysteria,  602 
P'lligge's  streptococcus,  218 
Focal  symptoms  in  brain  tumor,  719 
Fa?tid  breath  in  mercurial  ism,  358 
Fcetus,  cerebral  haemorrhage  in,  679 
small-pox  in,  263 
svphilis  in,  362 
Food,'  21 

diseases  due  to,  22 
inspection  of,  22 
Foot-and-mouth  disease,  519 
definition  of,  519 
diagnosis  of,  522 
etiology  of,  519 

period  of  incubation  in,  in  man, 
521 

in  cattle,  520 
prognosis  of,  522 
prophylaxis  of,  522 
symptomatology  of,  521 

in  cattle,  520 
synonyms  of,  519 
treatment  of,  522 
Foot-drop  in  external  popliteal  nerve  par- 
alysis, 847 
in  nniltiplc  alcoholic  neuritis,  808 
Fourth  nerve,  pnralysis  of,  S2] 
Fowler's  solution.     See  Arsenic. 
Freezing,  effect  of,  on  micro-organisms,  32 
Frictions  in  Raynaud's  disease,  862 
Friedreich's  ataxia,  795 
definition  of,  795 
diagnosis  of,  799 
etiology  of,  795 
morbid  anatomy  of,  796 
nystagmus  in,  798 
prognosis  of,  799 
static  ataxia  in,  797 
sym[>tomatoh)gy  of,  797 
svnonyms  of,  795 
ireatnient  of,  799 
Friedreich's     ataxia,    diagnosis    of,     from 
ataxic  paraplegia,  794 
from  insular  sclerosis,  7I.') 
Frontal  convolutions,  lesions  of,  720 
Fulminant  cerebro-spinal  fever,  169 


Fulminant  scarlatina,  220 
Functional  insanities,  547 
Fungus  haMuatodes,  718 
Furuncles  in  dengue,  199 

GAIT  in  antero-lateral  sclerosis,  790 
in  ataxic  jiaraplegia,  794 
in  lesions  of  the  cerebellum,  722 
in  diphtheritic  paralysis,  3S4 
in  Friedreich's  ataxia,  797 
in  hemijilegia,  085 
in  insular  sclerosis.  712 
in  locomotor  ataxia,  780 
in  multi])le  neuritis,  811 
in  chronic  periencephalitis.  554 
in  ]>seudo-hvpertropliic  muscular  atro- 

piiy,  854  ' 
in  Thomsen's  disease,  856 
Gait,  steppage,  in  external  popliteal  paraly- 
sis, S47 
in  peripheral  neuritis,  811 
Gall-bladder,  absce-ss  of,  in  tvphoid  fever, 

93 
Gallic  acid  in  typhoid  fever,  131 
Ganglia,  basal,  tumors  of,  721 
'  Gangrene  in  cerebro-spinal  fever.  174 
in  erysipelas,  400 
in  typhoid  fever,  93 
of  intestine  in  typhoid  fever,  80,  92,97 
of  lungs  in  relapsing  fever.  157 
in  scarlatina,  224 
in  typhoid  fever,  iSiS,  95 
in  typhus  fever,  144 
symmetrical,  8()0 
Garbage,  cremation  of,  16 
Gardeners,  mortality  of,  26 
Gastric  crises,  in  locomotor  ataxia,  779 
fever.     See  IxniiUlint  i]f(i/ariit/  Fever. 
form  of  typhoid  fever,  l(i2 
Gastritis,  diagnosis  of,  from  influenza,  193 
Gastro-enteric  catarrh,  diagnosis  of  from 

inthienza,  193 
Gastro-intestinal  form  of  inlhienza.  188 
Gas-workers,  diseases  of,  27 
Gelsemium  in  cerebro-spin^d  fever.  1S3 
General  paralysis  of  the  insane.     See  I'l ri- 

rnrtj)/i((/l/i.'<,  ( '/irnnlr. 
Genitalia,    alfection    of,   in    angio-neurotic 
oedema.  S62 
gangrene  of,  following  typhoid  fever,  97 
liy]>ertropliy  of,  in  acromegaly,  i^'^^t'^ 
Genito-urinarv  crises  in  locomotor  :itaxia, 

779 
German  measles.     See  lliiliillti. 
Germicides,  16 

Giant  growth,  diagnosis  of,  from  acromeg- 
aly, .S64 
urticaria.     See  Aiif/lo-inunific  UCilnna. 
Giberl's  syriiji  in  liercditiiry  sypliilis,  36S 
(lilies  de  l:i  Tourrette's  disease.     See  Antn- 

VKitir  C/iorcit  and  Fitv'ntl  Sjkikih. 
fUngivitis  in  mercurialism.  358 
(lirdie  sensation  in  locomotor  ataxia,  780 

in  acute  myelitis,  754 
Glanilers,  512 

in  aninnds,  512 


884 


INDEX. 


Glanders,  bacillus  of,  512 

cause  of,  11,  512 

complications  of,  515 

definition  of,  512 

diagnosis  of,  516 

etiology  of,  512 

morbid  anatomy  of,  516 

period  of  incubation  in,  513 

prognosis  of,  517 

prophylaxis  of,  517 

symptomatology  of  acute,  513 
of  chronic,  515 

synonyms  of,  512 

treatment  of,  518 
Glanders  bacillus,  512 

results  of  inoculation  of,  517 
Glass-workers,  mortality  of,  26 
Glioma  of  brain,  717 
Gliosis  in  epilepsy,  622 
Globus  hystericus,  595 
Glosso-labial  paralysis,  803 

symi)toniatology  of,  803 
Glosso-labio-laryngeal  paralysis,  852 
Glosso-pharyngeal  nerve,  lesions  of,  834 
Gluteal  reflex,  524 

Glycerin   suppositories    in    typhoid   fever, 
130 

in  typhus  fever,  149 
Glycosuria  in  cerebral  hsemorrhage,  682 

in  cerebro-spinal  fever,  176 

in  cholera,  443 

in  the  malarial  paroxysm,  417 

in  relapsing  fever,  158 

in  typhoid  fever,  97 
Gonococcus  as  cause  of  gonorrhoea,  11 
Gout  and  food,  22 

influence  of,  upon  ty|)hoid  fever.  111 
Gouty  insanity,  557 
Grandeur,  delusions  of,  537 
Granular  degeneration    of  muscles  in  ty- 
phoid fever,  64 
Gray  degeneration  of  spinal  cord,  759 
Grisolle  sign  in  small-pox,  279 
Grocers,  mortality  of,  26 
Gros  mal,  615 
Ground-water  in  relation  to  typhoid  fever, 

28,  54. 
Guinmata  in  acquired  syphilis,  350 

in  hereditary  syphilis,  365 

of  brain,  726 

of  kidney,  352 

of  liver,  352 

of  spinal  cord,  734 
Gunsmiths,  mortality  of,  26 
Gurjun  oil  in  leprosy,  372 
Gustatory  aurie  in  epilepsy,  615 

paralysis,  825 

HABIT  chorea,  634 
Habitations,  27 
Habitus,  apoplectic,  679 
Haematemesis  in  dengue,  198 
■     in  influenza,  190 
in  relapsing  fever,  157 
in  typhoid  fever,  84,  91 
in  typhus  fever,  145 


Haematidrosis  in  hysteria,  602 
Hsematoidin  in  brain    after    haemorrhage, 

681 
Hsematoma  of  the  dura  mater,  669 
Hsematomyelia.     See  Spinal  Apoplexy. 
Hsematomyelitis,  755 
Hsematorrhachis,  741 
Heematuria  in  measles,  244 

in  relapsing  fever,  155 

in  scarlatina,  220 

in  typhoid  fever,  97 
Hsematuric  form  of  malarial  fever,  427 
Haemic  murmurs  in  relapsing  fever,  155 
Haemoglobinuria   and   Raynaud's   disease, 

861 
Haemoptysis  in  scarlatina,  224 

in  typhoid  fever,  95 
Haemorrhage  in  anthrax,  481 

in  congestive  cardiac  epilepsy,  618 

in  hsematuric  intermittent  fever,  427 

in  hysteria,  601 

intracerebral,  681 

in  measles,  244 

meningeal,  680 

in  typhoid  fever,  67 

in  the  retina,  815 

in  small-pox,  274 

into  spinal  cord,  745 
membranes,  741 

in  typhoid  fever,  131 

ventricular,  681 

in  yellow  fever,  456 
Hajmorrhagic  diathesis  in  typhoid  fever,  95 

pachymeningitis.    See  Pachymeningitis, 
Hallucinations,  definition  of,  533 

in  delirium  tremens,  559 

in  melancholia,  563 

in  paranoia,  582 

sources  of,  534 
Hatters,  mortality  of,  26 
Hay  bacillus,  16 
Headache,  654 

classification  of,  654 
nervous,  656 
organic,  654 
sympathetic,  656 
toxfemic,  655 
Headache  in  acromegaly,  864 

in  brain  syphilis,  727 

in  brain  tumors,  718 

in  cerebro-spinal  fever,  171 

in  influenza,  187-189 

in  relapsing  fever,  155 

in  scarlatina,  224 

in  simple  meningitis,  674 

in  small-pox,  267 

in  tuberculous  meningitis,  671 

in  typhoid  fever,  79 

in  typhus  fever,  138 
Health  boards,  duties  of,  44 
Heart,  dilatation  of,  in  typhoid  fever,  93 

disease,  influence  of  influenza  on,  192 
influence  of,  in  typhoid  fever,  112 
valvular,  in  locomotor  ataxia,  784 
in  typhoid  fever,  93 

murmur  in  St.  Vitus's  dance,  631 


INDEX. 


885 


Heart-muscle,  typhoid  bacilli  in,  56 
Heat  as  a  disinfectant,  16 

effect  of,  on  poison  of  scarlatina,  213 
exhaustion,  645 

influence  of,  on  typhoid  bacillus,  57 
moist,  as  a  disinfectant,  17 
Heating  by  direct  method,  40 
direct-indirect  method,  39 
indirect  method,  39 
Hebephrenia,  580 
Hebetude  in  typhoid  fever,  78 
Hemeralopia,  815 
Hemiachi'omatopia,  818 
Heniianjesthesia   in  cerebral  haemorrhage, 
685 
in  hemiplegia,  685-708 
in  hysteria,  601 

in  lesion  of  the  internal  capsule,  721 
in  spinal  tumor,  747 
Hemianopia,  818 

hemiopic  pupillary  inaction  in,  819 
heteronymous,  818 
homonymous,  818 
nasal,  818 
significance  of,  818 
temporal,  818 
Hemiplegia,     following    cerebral    haemor- 
rhage, 683 
in  cerebro-spinal  fever,  173 
contractures  in,  685 
crossed,  in  cerebral  hsemorrhage,  684 
in  hsemorrhagic  pachymeningitis,  670 
in  hysteria,  599 
infantile,  706 

aphasia  in,  707 
contractures  in,  707 
convulsions  in,  707 
epilepsy  in,  708 
mental  defects  in,  708 
morbid  anatomy  of,  706 
post-hemiplegic  movements  in,  708 
symptomatology  of,  707 
and  Raynaud's  disease,  861 
spastica  cerebralis,  708 
Hemipl^gie  fla'^que,  708 
Hepatitis  in  typhoid  fever,  92 
Hereditary  chorea,  637 

definition  of,  637 
etiology  of,  637 
pathology  of,  637 
symptomatiijogy  of,  637 
treatment  of,  638 
immunity  from  disease,  13 
tendency  to  disease,  8 
Heredity  in  etiology  of  acromegaly,  863 
of  angio-iH'urotic  fjedema,  S62 
of  cerebral  luemorrhage,  679 
of  epilepsy,  612 
of  l'"ri('(lreicirs  ataxia,  795 
of  hysteria,  593 
of    idiopatliic    muscular    atro|)hy, 

85-J 
of  leprosy,  369 
of  muscular  atrophy,  854 
of  peroneal  type  of  muscular  atro- 
phy, 856 


Heredity  in  etiology  of  progressive  muscu- 
lar atro])hy,  799 
of  scrofula,  33(5 
of  Thonisen's  disease,  856 
Herpes  in  cerebro-spinal  fever,  174 
in  dengue,  198 
in  ephemeral  fever,  47,  48 
in  paralysis  of  facial  nerve,  830 

of  filth  nerve,  825 
labialis  in  malarial  fever,  414 

in  typhoid  fever,  '^2 
zoster  in  intercostal  neuralgia,  845 
in  localized  neuritis,  806 
in  chronic  periencephalitis,  555 
Hiccough,  841 

in  cholera,  442 
in  relapsing  fever,  157,  161 
treatment  of,  841 
in  typhoid  fever,  81 
in  tvphus  fever,  143 
Hippus,'824 

Hog  cholera,  cause  of,  12 
Hospitals  for  contagious  diseases,  21 
Hot  air  as  a  disinfectant,  17 
House  sewerage,  35 
Hucksters,  mortality  of,  26 
Human  lymph,  objections  to  use  of,  in  vac- 
cination, 294 
Huntingdon's     chorea.        See     Hereditary 

Chorea. 
Hutchinson's  teeth,  364 
Hyaline  degeneration  of  muscle-fibres,  850 
Hydatid  of  brain,  718 
Hydrargyrum.     See  Afercurt/. 
Hydrocephalic  cry  in  tuberculous  menin- 
gitis. 672 
Hydrocephalus,  chronic,  723 
acquired,  724 
infantile,  723 
morbid  anatomy  of,  723 
symptomatology  of,  725 
treatment  of,  725 
Hydrocephalus     following     cerebro-spinal 
fever,  167 
ex  vacuo,  723 

internal,   in   chronic   periencephalitis, 
551 
Hydrocephalus,  diagnosis  of,  from  rachitis, 

724 
Hydrochloric  acid  as  a  disinfectant,  20 
Hydrocyanic  acid  in  milk-sickness,  206 

"  in  typhoiil  fever,  128 
Hydrogen  peroxide  in  diphtheria,  393 
Hydro-pericardium  in  scarlatina,  219 
Hydr()p!i<)l)ia,  4S5 

Centaiiiii's  metiujd  in,  497 
definition  of,  485 
diagnosis  of",  494 

ill  the  dog,  489 
etiology  of,  485 
morbid  anatomy  of,  491 
I'astcur's  method  in,  497 
period  of  iiiciiltalioii  in,  489 
prognosis  of,  495 
j)ropliyla.\is  of,  495 
Hyiiiptiiiiiatology  of,  492 


886 


INDEX. 


Hydrophobia,  synonyms  of,  485 

treatment  of,  496 
Hydrophobia,  diagnosis  of,  from  lyssopho- 
bia,  495 
from  tetanus,  468,  494 
Hydrophobia  in  the  dog,  486 
Hydrops.     See  (Edema. 
Hydrotherapy.     See  Baths. 
Hydrothorax  in  scarlatina,  219 
Hygiene,  1 

in  diphtheria,  388 

in  scrofula,  342 

in  syphilis,  360 

in  typhus  fever,  147 
Hyoscine  in  delirium  tremens,  560 

in  erysipelas,  403 

in  melancholia,  567 

in  acute  periencephalitis,  550 

in  typhoid  fever,  128 

in  typhus  fever,  149 
Hyperacusis,  833 

in  hysteria,  600 
Hypersesthesia  in  cerebro-spinal  fever,  172 

in  hysteria,  599 

in  relapsing  fever,  155 

of  retina,  815 

in  typhoid  fever,  81 

in  typhus  fever,  140 
Hyperbulia,  530 
Hyperpyrexia  in  cerebro-spinal  fever,  175 

in  cholera,  443 

in  dengue,  198 

in  diphtheria,  381 

in  ephemeral  fever,  48 

in  epilepsy,  614 

in  erysipelas,  400 

in  hysteria,  602 

in  influenza,  188 

in  intermittent  fever,  414 

in  measles,  241 

in  relapsing  fever,  160 

in  rubella,  258 

in  scarlatina,  215 

in  small-pox.  266 

in  tetanus,  467 

in  thermic  fever,  646 

in  acute  miliary  tuberculosis,  333 

in  tulaerculous  meningitis,  672 

in  typhoid  fever,  74-76,  118 

in  typho-malarial  fever,  432 

in  typhus  fever,  140,  144 

as  cause  of  degeneration  of  muscles,  64 

treatment  of,  118 
Hypnotism  in  hysteria,  608 
Hypochondria  in  Thomsen's  disease,  857 
Hypochondriacal  delusions.    See  Delusions. 
Hypodermoclysis  in  cholera,  448 
Hypoglossal  nerve,  paralysis  of,  839 
Hypomania,  569 
Hypophosphites  in  scrofula,  343 
Hypostatic  congestion  of  lungs  in  typhoid 

fever,  66 
Hysteria,  592 

age,  heredity,  race,  and  sex  in  etiology 
of,  593 

amblyopia  in,  601 


Hysteria,  anjesthesia  in,  600 

anorexia  in,  602 

beast-mimicry  in,  595 

catalepsy  in,  598 

catheterization  in,  609 

convulsions  in,  596 

definition  of,  592 

diagnosis  of,  603 

disturbances  of  consciousness  and  mo- 
tion in,  595 
of  sensation  in,  599 

dyspnoea  in,  602 

etiology  of,  592 

in  etiology  of  local  syncope,  859 

faecal  vomiting  in,  603 

hemiplegia  in,  599 

hyperaestbesia  in,  599 

hypnotism  in,  608 

ischsemia  in,  600 

joint  affections  in,  603 

mental  symptoms  in,  594 

metallo-therapy  in,  note,  601 

monoplegia  in,  599 

muscular  atrophy  in,  852 

opisthotonos  in,  596 

paralysis  in,  599 

paraplegia  in,  599 

pathology  of,  605  _ 

photophobia  in,  600 

prognosis  of,  605 

pseudo-angina  pectoris  in,  601 

relation  of,  to   paramyoclonus   multi- 
plex, 858 

respiration  in,  602 

rest-treatment  in,  606 

sweating  in,  602 

symptomatology  of,  593 

temperature  in,  602 

trance  in,  598 

treatment  of,  606 

urinary  function  in,  602 
Hysteria,  diagnosis  of,  from  cerebro-spinal 
fever,  179 

from  epilepsy,  619 
Hysterical  breast,  604 

contractures,  diagnosis  of,  from  spinal 
contractures,  792 

dyspnoea,  602 

insanity,  558 

joints,  peculiarities  of,  603 

diagnosis  of,  from  arthritis,  603 

paralyses,  peculiarities  of,  603 

somnolence,  598 

ICE  in  thermic  fever,  648 
typhoid  bacilli  in,  57 
Ice-cap  in  erysipelas,  403 

in  meningitis,  676 
Ichthyol  in  typhoid  fever,  132 
Icterus.     See  Jaundice. 
Idiocy  in  infantile  hemiplegia,  708 

and  idiopathic  muscular  atrophy,  855 
Idiopathic   muscular    atrophies,   diagnosis 

of,  from  spinal  atrophies,  855 
Idiopathic  muscular  atrophy,  851 
diagnosis  of,  855 


! 


INDEX. 


887 


Idiopathic  muscular  atrophy,  morbid  anat- 
omy of,  855 
prognosis  of,  856 
treatment  of,  ^bi!) 
Idiopathic  pyaemia,  32G 
Ileum,  changes  in,  in  typhoid  fever,  65 
Ilium,    periostitis    of,    following    typhoid 

fever,  90 
Illusions,  definition  of,  534 
Immunity,  13 

during  epidemics,  13 
transmitted  by  heredity,  8 
from  diphtheria,  375,  378 
from  scarlatina,  210 
from  tetanus,  470 
from  yellow  fever,  453 
Immunity  conferred  l)y  measles,  235 
by  mumps,  307 
by  rubella,  259 
by  scarlatina.  221 
by  small-pox,  263 
by  vaccination,  289 
Imperative  act,  539 
conce{)tion,  539 
Incoherence,  varieties  of,  533 
Incontinence  of  faeces  in  typhoid  fevei',  113 
of  urine  in  cerebro-spinal  fever   169, 
176 
in  typhoid  fever,  89 
Indigestion  as  a  cause  of  fever,  47 
Infantile  type  of  muscular  atrophy,  854 
Infantile     paralysis.        See      Fo/iomi/elifis, 

Acute. 
Infants,  fatality  of  smuU-pox  in,  280 

typhoid  fever  in,  103 
Infection  through  clothing,  25 
Influenza,  184 

cause  of,  12,  185 
complications  of,  189 
definition  of,  184 
diagnosis  of,  192 
etiology  of,  184 
history  of,  184 
morbid  anatomy  of,  187 
mortality  of,  193 
nature  of,  184 
prognosis  of,  193 
sequelae  of,  189 
symptomatology  of,  187 
synonyms  of,  184 
treatment  of,  194 
Influenza,  diacrnosis  of,  from  cerebro-spinal 
fever,  17H,  193 
from  dengue,  199 
from  typhoid  fever,  108,  193 
Influenza  with  typhoid  fever,  97 
Initial  eruptions  in  small-pox,  267 
Injections,     sulicntaneous,     of    salines     in 
cholera,  448 
protective,  in  tetanus,  470 
Injuries,  remote  effects  of,  642 
liuikeepers,  mortality  of,  26 
Inoculation  experiments  in  infhienza.  1.S5 
in  scarlatina,  213 
against  small-pox,  291 
in  typhoid  fever,  57 


Inoculation  experiments  in  varicella,  299 
Inoculations,    protective,    in    hvdropliobia, 

497 
Insanity,  I'lassitieation  of,  546 
definition  of,  543 
post-typhoidal,  90 
See,  also,  Ah-ofio/ic,    Circular,    C'oniji/ica- 
ting,       Con/usioiKi/,        ( hns/itiitiondl, 
Doubfiiui,     Funrfionnl,    Goutij,    Hijs- 
terical,  Morul,   yvuropathir,  Or;/titiic, 
Periodical,  Pure,  Pcasouiii;/,  and  lox- 
(P)iiic  InsanUji. 
Insects  as  conveyers  of  anthrax,  480 
Insolation.     See  Thermic  Fever. 
Insomnia,  simjile,  6t)0 

treatment  of,  6<)0 
Insomnia  in  brain  syphilis,  728 
in  delirium  tremens,  559 
in  influenza,  188 
following  influenza,  192 
in  mania,  568 
in  melancholia,  564 
in  acute  periencej>halitis,  549 
in  trichinosis,  507 
in  typhoid  fever,  79,  127 
treatment  of,  660 
Inspiration,   contraction   of  typhoid  fever 

by,  54,  57,  58 
Insula,  tumors  of,  721 
Insular  sclerosis,  711 

diagnosis  of,  712 
etiology  of,  711 
morbid  anatomy  of,  711 
prognosis  of,  713 
symptomatology  of,  712 
treatment  of,  713 
Insular  sclerosis,  diagnosis  of,  from  Fried- 
reich's ataxia.  713 
Intellectual  aura*  in  epilepsy,  (il5 
Intellectual    functions,   general   considera- 
tions on,  532 
Intention  tremors,  526 
Intermittent  fever.     See  Malarial  Fcrrrs. 
Intermittent  form  of  cerebro-spinal  fever, 

170 
Internal  ca])sule,  lesions  of,  7<I0 
tracts  in,  61t7 
tumors  of,  721 
Internal  carotid  artery,  occlusion  of,  ilitl 
Interstitial  keratitis  in  liereditary  sypliilis, 

3(!(; 
Intestinal  crises  in  locomotor  ataxia,  779 
Intestinal  gangrene  in  typlioid  fV-ver,  92 
Intestinal  glands  in  typlioid  fever,  (il 

typlioid  bacilli  in,  56 
Intestinal  lucniorrliage.  Sec  Fnlrrorrliarfia. 
Intestine,  jierforation  of.  in  tvplioid   fevi-r, 

92 
Intestines,  cbaiiges  in,  in  clioh'ra,  439 
in  typlioid  fever,  61 
in  yellow  fever,  455 
Iiil  ravenous  inicctioiis  in  typhoid  fever,  131 
intubation  in  diplillieria,  3*.)3 
Iodide  eruptions,  .359 
Iodide  of  iron  in  scrofula,  343 
of  potas.Hiiiiii  in  leprosy,  372 


888 


INDEX. 


Iodide  of  potassium  in  syphilis,  358 
in  brain  syphilis,  733 
in  hereditary  syphilis,  367 
in  whooping  cough,  321 
Iodide  test  in  syphilis,  355 
Iodine  in  typlioid  fever,  125,  127,  133 
lodism,  symptoms  of,  359 
Iodoform   in  typhoid  fever,  125,  127,  129, 

132 
Ipecacuanha  in  delirium  tremens,  560 

in  measles,  252 

in  whooping  cough,  321 
Irido-choroiditis    in    cerebro-spinal     fever, 

173 
Iridoplegia,  821 

accommodative,  821 

loss  of  skin  reflex  in,  821 

reflex,  782,  821 
Iron  after  cerebro-spinal  fever,  183 

in  confnsional  insanity,  574 

in  neuralgia  of  fifth  nerve,  827 

in  Raynaud's  disease,  S62 

after  typhoid  fever,  1 33 

after  typhus  fever,  149 
Ischsemia  in  hysteria,  600 
Isolation,  21 

in  diphtheria,  388 

in  leprosy,  21,  372 

in  measles,  251 

in  relapsing  fever,  160 

in  scarlatina,  225 

in  small-pox,  280 

in  typhus  fever,  147 

in  yellow  fever,  459 

JACKSONIAN  epilepsy,  620,  699,  719 
Jaundice  in  bilious  intermittent  fever, 
426 
in  cerebro-spinal  fever,  176 
in  dengue,  199 
in  influenza,  190 
in  relapsing  fever,  155,  161 
in  remittent  malarial  fever,  424 
in  typhoid  fever,  92,  99 
in  typhus  fever,  145 
in  yellow  fever,  456 
Jaw  reflex  in  spastic  bulbar  paralysis,  795 
Jaw  sarcoma  in  cattle,  474 
Joint  affections,  peculiarities  of  hysterical, 

603 
Joints,  ankylosis  of,  in  selerodactyle,  865 
fixation  of,  in  scleroderma,  866 
lesions  of,  in  hereditary  syphilis,  364. 
See,  also.  Arthritis. 
Jumpers.     See  Antoinatic  Chorea. 
Jurisjirudence,  sanitary,  43 
.Juvenile  form  of  muscular  atrophy,  854 

KATATONIA,  note  on,  565 
Keloid  of  Addison.    See    Scleroderma. 
Keratitis  in  scarlatina,  223 
in  small-pox,  277 

interstititial,  in  hereditary  syphilis,  364 
Kerato-malacia  in  scarlatina,  223 
Kidnevs,  amyloid  change  in,  in  acquired 
'syphilis,  352 


Kidnevs,  changes  in,  in  cerebro-spinal  fever, 
'166 

in  cholera,  439 
in  relapsing  fever,  154 
in  typhoid  fever,  66 
in  typhus  fever,  137 
in  yellow  fever,  454 
infarcts  of,  in  relapsing  fever,  154 
in  typhoid  fever,  66 
tubercles  in,  in  acute  miliary  tubercu- 
losis, 332 
Klebs-Loeffler  bacillus,  273 
Kleptomania,  585 

Knee-clonus  in  antero-lateral  sclerosis,  791 
Knee-jerk,  525 

in  antero-lateral  sclerosis,  791 
in  cerebral  hsemorrhage,  685 
in  diphtheritic  paralysis,  384 
in  epilepsy,  615 
in  Friedreich's  ataxia,  797 
in  locomotor  ataxia,  780 
in  spinal  apoplexy,  746 
in  s])inal  neurasthenia,  644 
in  trichinosis,  506 
in  tuberculous  meningitis,  108 
in  typhoid  fever,  82,  108 
Koch's    tuberculin,    action    of,     in   tuber- 
culosis, 330 
Kyphosis  in  acromegaly,  863 

LABORERS,  mortality  of,  26 
Lactophosphates  in  scrofula,  343 
La  grippe.     See  Influenza. 
Landouzy-Dejerine  type  of  anterior  polio- 
myelitis, 852 

of  progressive  myopathic  atrophy, 
852 
Landry's    paralysis.     See   Acute  Ascending 

Paralysis. 
Lanolin  for  inunction  in  scarlatina,  226 
Laparotomy  in  typhoid  fever,  131 
Lardaceous  degeneration.     See  Amyloid. 
Laryngeal  crises  in  locomotor  ataxia,  779 
Laryngeal  diphtheria,  382 
Laryngismus  in  measles,  244 
Laryngitis  in  typhoid  fever,  95 
Laryngo-typhoid,  99 
Larynx,  adductor  paralysis  of,  836 
anjesthesia  of,  836 
bilateral  abductor  paralysis  of,  836 
diphtheritic  inflammation  of,  in  typhoid 

fever,  66 
hypersesthesia  of,  836 
oedema  of,  in  angio-neurotic  oedema,  862 
in  erysipelas,  400 
in  typhoid  fever,  95 
unilateral  abductor  paralysis  of,  836 
Latah.     See  Automatic  Cliorea. 
Latent  mahirial  fever,  417 

form  of  typhoid  fever,  101 
Lateral  sclerosis.     See  Antero-lateral  Scle- 
rosis. 
Lawyers,  mortality  of,  26 
Laxatives  in  St.  Vitus's  dance,  632 
Lead  acetate  in  typhoid  fever,  129,  131 
paralysis,  852 


ixin:x. 


889 


Lead-water   and  laudanum    in    erysipelas 

402 
Lead-workers,  mortality  of,  2G 
Leiter's  tubes,  118 
Lemon-juice  in  typhoid  fever,  116 
Leontiasis,  370 
Lepers,  isolation  of,  21,  372 
Leprosy,  3(59 

ana?sthetic  or  nerve,  371 
bacillus  of,  370 
cause  of,  11,  370 
causes  of  death  in,  372 
contagiousness  of,  370 
definition  of,  369 
diagnosis  of,  371 
etiology  of,  3(59 

history  and  distribution  of,  369 
morbid  anatomy  of,  370 
prognosis  of,  372 
prophylaxis  of,  372 
symptomatology  of,  370 
treatment  of,  372 
tubercular,  370 
Leprous  neuritis,  852 
Leptomeningitis,  acute  spinal,  741 
chronic,  676 

following  scarlatina,  218 
Leptomeningitis  infantum,  675 
morbid  anatomy  of,  675 
symptomatology  of,  676 
Leucoderma  in  scleroderma,  865 
Leyden-Mobius  type  of  progressive  myo- 
pathic atrophy,  852 
Life,  expectation  of,  (5 
Lightning  pains  in  locomotor  ataxia,  778 
Lime-water  in  diphtheria,  392 
Linea  albicantes  in  typhoid  fever,  90 
Liquor-dealers,  mortality  of,  26 
Liver,  abscess  of,  in  tvphoid  fever,  65,  92, 
93 
actinomycosis  of,  477 
amvloid  change  in,  in  acquired  syphilis, 

352 
changes  in,  in  hereditary  syphilis,  363, 
365 

in  typhoid  fever,  92 
in  yellow  fever,  454 
embf)Iism  of,  in  typiioid  fever,  65 
enlargcmiMit  of,  in  relapsing  fever,  154 

in  typiius  fever,  l.')9,  141 
tubercles  in,  in  acute  miliary  tubercu- 
losis. 331 
Local  asphyxia,  859 
Local  chorea,  526 
Local  syncope,  859 
Locality  in  etiology  of  malarial  fevers,  410 

of  yellow  fever,  453 
Localization,  cerebral,  69('i 
in  cerel)ral  tumor,  720 
spinal,  739 
Lockjaw.     Sec  TclinniH. 
Locomotor  ataxia,  776 

Argyll- Robertson  [)Upil  in,  782 
complications  of,  784 
crises  in,  778 
definition  of,  77<5 


Locomotor  ataxia,  diagnosis  of,  784 
etiology  of,  777 
gait  in,  780 
pathology  of,  776 
perforating  ulcer  in,  783 
sensory  disturbances  in,  778 
symptomatology  of,  778 
synonyms  of,  776 
termination  of,  784 
treatment  of,  786 
trophic  changes  in,  782 
valvular  heart  disease  in,  784 
Locomotor  ataxia,  diagnosis  of,  from  abasia- 
astasia,  784 

from  multiple  peripheral  neur- 
itis, 785,  811 
Long  thoracic  nerve,  aflections  of,  843 
Lues  venerea.     See  Sj/philijf. 
Lumbar  nerves,  affections  of,  8-16 
Lungs,  abscesses  of,  in  typhoid  fever,  66,  95 
actinomycosis  of,  476 
changes  in,  in  typhus  fever,  137 
collapse  of,  in  typhoid  fever,  95 
congestion  of,  in  cerebral  hajmorrhage, 
683 

in  typhoid  fever,  103,  132 
in  typhus  fever,  144 
embolism  of,  in  typhoid  fever,  110 
gangrene  of,  following  influenza,  190 
in  relapsing  fever,  157 
in  scarlatina,  224 
in  typhoid  fever,  95 
in  typhus  fever,  144 
gunimata  of,  in  hereditary  syphilis,  365 
hypostatic   congestion   of,   in    typhoid 

fever,  06,  95 
infarcts  of,  in  relapsing  fever,  153 

in  typhoid  fever,  66,  95 
influenza-bacillus  in,  185,  187 
oedema  of,  in  cerel>ro-spinal  fever.  166 
in  influenza,  18!) 
in  scarlatina,  224 
in  typhoid  fever,  (56,  95 
splenization  of,  in  typhoid  fever,  66 
tubercles  in,  in  acute  miliary  tuberculo- 
sis, 331 
Lymphatic  glands,  enlargement  of,  in  scrof- 
ula, 338 

inflammation  of,  in  anthrax,  481 

in  scrofula,  3;'>9 
involvement  of,  in   acute  ascend- 
ing paralysis,  749,  750 
ill  (lipli'tlifria,  380 


III  nibi'lla. 


.".8 


in  syphilis,  349 
in  hereditary  sy|»hilis,  3(5(5 
in  ty|)lioid  fever,  (51,  63 
tubercles  in,  in  atiite  miliary  tuber- 
culosis, .'{.'tl 
Lymph-vaccine,  292 
liVssa.     See  I/i/ifro/i/iohin. 
Lvssoplioi)ia,  liiagiiosis  of,  from  hydropho- 
bia. 495 


M 


ACJilNlvMAKHllS,  mortality  of,  26 

Main  en  grifl'c,  801 


890 


INDEX. 


Malaria,  405 
Malarial  cachexia,  432 

treatment  of,  433 
Malarial  fevers,  405 

age,  race,  and  sex  in  etiology  of, 
410 

altitude  and  soil  in  etiology  of,  411 

in  lower  animals,  412 

anticipating,  406 

classification  of,  412 

climate,  locality,  and  season  in  eti- 
ology of,  410 

definition  of,  405 

duplicated  forms  of,  406 

etiology  of,  407 

hsematozoon  of,  407 

mode  of  infection  in,  409 

micro-organisms  in,  407 

mortality  of,  430 

period  of  incubation  in,  413 

Plasmodium  malarise  in,  407 

prophylaxis  of,  419 

quartan,  405 

quinine  in,  421 

quotidian,  405 

relation  of,  to  phthisis,  412 

retarding,  406 

synomyms  of,  405 

tertian,  405 

types  of,  405 
intermittent  malarial  fever,  412 

diagnosis  of,  418 

exceptional  cases  of,  417 

morbid  anatomy  of,  412 

paroxysm  of  413 

period  of  incubation  in,  413 

prognosis  of,  419 

symptomatology  of,  413 

terminations  of,  418 

treatment  of,  420 
pernicious  intermittent  malarial  fever, 
425 

algid  type  of,  427 

asthenic  type  of,  427 

bilious  type  of,  426 

comatose  type  of,  428 

complications  of,  428 

diagnosis  of,  428 

haematuric  type  of,  427 

sequeke  of,  428 

symptomatology  of,  426 

synonyms  of,  425 

treatment  of,  430 

types  of,  426 
pernicious  remittent  malarial  fever,  431 
remittent  malarial  fever,  423 

complications  of,  425 

diagnosis  of,  425 

duration  of,  425 

morbid  anatomy  of,  423 
'  prognosis  of,  425 

symptomatology  of,  424 

treatment  of,  425 
typho-malarial  fever,  etiology  of,  431 

symptomatology  of,  431 

treatment  of,  432 


Malarial  fevers,  diagnosis  of,  from  cerebro- 
spinal fever,  179 
from  cholera,  429 
from  ephemeral  fever,  49 
from  meningitis,  429 
from  miliary  fever,  203 
from  pneumonia,  419 
from  pyaemia,  328,  419,  429 
from   acute    miliary   tuberculosis, 

334 
from  typhoid  fever,  107,  429 
from  ulcerative  endocarditis,  429 
from  yellow  fever,  429,  458 
Malarial  typhoid,  97 
Mai  de  montagne,  610 
Malignant  cerebro-spinal  fever,  169 
scarlatina,  220 
typhoid  fever,  102 
typhus  fever,  144 
Malignant  redema,  cause  of,  12 
Malignant  pustule.     See  Anthrax. 
Mallein,  513 

action  of,  517 
Mammary  glands  in  hysteria,  604 
Mania,  acute,  567 

definition  of,  567 
symptomatology  of,  567 
Mania,  chronic,  569 

symptomatology  of,  569 
Mania  in  epilepsy,  617 

following  influenza,  192 
Mania  a  potu.     See  Delirium  Tremens. 
Maniacal  epileptic  automatism,  617 
Marantic  thrombi,  094 
Marie's  disease.     See  Acrornec/aly. 
Marriage,  question  of,  in  epilepsy,  624 

in  syphilis,  8,  367 
Marrow    of  bones   in    hereditary   syphilis, 
364 

tubercles     in,    in    acute     miliary 
tuberculosis,  332 
Masked  malarial  fever,  417 
Massage  in   idiopathic  muscular  atrophy, 
856 

in  neurasthenia,  592 
in  acute  poliomyelitis,  770 
Mastication,  spasm  of  the  muscles  of,  826 
Mastodynia,  845 
Matchmakers,  diseases  of,  26 
Maxima  of  temjterature  in  typhoid  fever, 

76 
Measles,  230 

associated  diseases  in,  235 

complications  and  sequelae  of,  243 

definition  of,  230 

diagnosis  of,  249 

etiologv  of,  232 

history  of,  230 

morbid  anatomy  of,  250 

mortality  of,  251 

prognosis  of,  251 

prophylaxis  of,  251 

relations  of,  to  tuberculosis,  249 

symptomatology  of,  237 

synonyms  of,  230 

treatment  of  251 


INDEX. 


891 


Measles,diagno.sis  of,  from  miliary  fever,  202 
from  rubella,  259 
from  scarhitina,  221 
from  sin;ill-|>()x,  278 
from  syphilis,  355 
from  typhus  fever,  147,  250 
Meat,  inspection  of,  22 

for  tricliinse,  501 
Median  nerve,  allections  of,  844 

paralysis  of,  844 
Medical    experts,    function    of,   in  railway 

cases,  (544 
Medulla,  tumors  of,  721 
Melsena.     See  Enterorrhaijia. 
Melansemia  in  malarial  fever,  423 
Melancholia,  562 
agitata,  5(36 
attonita,  565 
classification  of,  565 
course  of,  566 
definition  of,  562 
periodical,  586 
prognosis  of,  566 
simple  forms  of,  565 
symptomatology  of,  562 
treatment  of,  567 
Melanosis  in  malarial  fevers,  423 
Membranous  croup,    relation   of,  to  diph- 
theria, '.^m 

diagnosis  of,  from  diphtheria,  386 
Memory  and  consciousness,  correlated  dis- 
orders of,  664 
Meniere's  disease,  611 
Mt'ningite  foudroyante,  169 
Meningitis,  simple,  673 

diagnosis  of,  675 
etiology  of,  673 
morbid  anatomy  of,  674 
symptomatology  of,  674 
treatment  of,  676 
Meningitis  in  cerebro-spinal  fever,  170 
in  erysipelas,  400 
in  scarlatina,  218,  223 
in  typhoid  fever,  90 
in  typhus  fcvcM-,  145 
Meningitis,  diagnosis  of,  from  cerebro-spinal 
fever,  179 
from  malarial  fever,  429 
from  small-pox,  278 
from  tetanus,  468 
Meningitis,  acute  spinal,  741 

symptomatology  of,  742 
treatment  of,  742 
Meningitis,  chronic  spinal,  743 

treatment  of,  743 
Meningitis  siderans,  169 
Meningitis,   tuberculous.     See    Tuberculous 

Mi'iiiiHiHiK  and  LfptonK'niiKjifis. 
Men.ilrual     blood.    s|iirilhim    of    relapsing 

fever  in,  15] 
Menstruation  in  ty[>hoid  fever,  97 

in  acromegaly,  863 
Mental  causes  of  diseases,  8 
Mental  changes  in  Tliomsen's  <lisease,  857 
Mental  diseases,  general  considerations,on, 
629 


Mental  powers,  exaltation  of  the,  532,  <o&io 

failure  of  the,  532,  i^^ 
Mental  symptoms  in  brain  syphilis,  729 

in  multiple  alcoholic  neuritis,  808 
Menihol  in  typhoid  fever,  127 
Mercurial  inunctions,  method  of  applving, 

733 
Mercurialism,  symptoms  of,  358 
Mercury  in  anthrax,  483 

in  brain  syphilis,  732 

in  cerebro-spinal  fever,  182 

in  diphtiieria,  392,  395 

in  locomotor  ataxia,  786 

in  chronic  myelitis,  7(>(> 

in  chronic  periencephalitis,  556 

in  acute  poliomyelitis,  769 

in  snuill-pox,  282 

in  syphilis,  356 

in  hereditary  syphilis,  367 

in  typhoid  fever,  127 
Merismopedia  gonorrho^ie,  11 
Mesenteric   glands,  involvement  of,  in  ty- 
phoid fever,  63 
Metallic  subacute  poliomyelitis,  772 
Metallo-therapy  in  hysteria,  note  on,  601 
Metastasis  in  actinomycosis,  476 

in  mumps,  308 
Metastatic  abscesses  in  pytiemia,  327 

carbuncles  in  anthrax,  481 
Metastatic  parotitis,  3(>9 

symptomatology  of,  310 
Meteorism  in  hysteria,  602 

in  locomotor  ataxia,  779 

in  ty])h()id  fever,  83 

in  typhus  fever,  141 
Metschnikoff,  vibrio  of,  12 
Micrococci.     See  Micro-orgnniHinx. 
Micro-organisms,  diseases  due  to,  9 

in  actinomycosis,  475 

in  acute  ascending  paralysis,  750 

in  anthrax,  478 

in  cerebro-spinal  fever,  165 

in  cholera  sttiols,  441 

in  dengue,  197 

in  diplitheria,  373 

in  erysipelas,  3!»7,  398 

in  foot-and-mouth  disease,  520 

in  malarial  fevers,  407 

in  measles,  23(5 

in  metastatic  parotitis,  309 

in  mumps,  305 

in  pya-mia,  326 

in  relapsing  fever,  150 

in  niliella,  255 

in  scarlatina,  213 

in  septica'inia,  324,  325 

in  small-pox,  2(i4 

in  typiioid  fever,  55 

in  varicelbi,  29i( 

in  water,  W 

in  yellow  fever,  451 
Middle  eereiiral  artery,  occlusion  of,  ()91 
Mieseherian  sac,  5(11 
Migraine,  65() 
I  diagnosis  of,  (559 

'  ophllialmic  type  of,  658 


892 


INDEX. 


Migraine,  symptomatology  of,  656 

treatment  of,  659 
Miliary  fever,  201 

definition  of,  201 
diagnosis  of,  202 
etiology  of,  201 
history  of,  201 
morbid  anatomy  of,  202 
prognosis  of,  203 
symptomatology  of,  202 
synonyms  of,  201 
treatment  of,  203 
Miliary  fever,  diagnosis  of,  from  malarial 
fever,  203 
from  measles,  202 
from  rheumatic  fever,  202 
Miliary  tuberculosis,  acute.     See   Tubercu- 
losis, Acute  Miliary. 
Milk  as  convever  of  infection  in  diphtheria, 
22,"  376 
in  scarlatina,  22,  211 
in  tuberculosis,  22 
in  typhoid  fever,  22,  59,  113 
and  disease,  22 
as  food,  22 

sterilization  of,  23 
Milk  in  measles,  251 

in  relapsing  fever,  160 
in  scarlatina,  227 
in  typhoid  fever,  115 
in  typhus  fever,  148 
Milk  sickness,  204 

definition  of,  204 

diagnosis   and    relation    to   other 

diseases,  206 
etiology  of,  204 
symptomatology  of,  204 
synonyms  of,  204 
treatment  of,  206 
Millers,  mortality  of,  26 
Milzbrand  bacillus,  478 
Mind-blindness,  703 
Mind-deafness,  704 
Mineral    poisoning,    acute,    diagnosis    of, 

from  cholera,  445 
Miners,  mortality  of,  26 
Minima  of  temperature  in  typhoid    fever, 

76 
Miryachit.     See  Automatic  Chorea. 
Mitchell,   S.   Weir,    treatment.      See    Rest 

Treatment. 
Monoplegia,  definition  of,  523 
in  hysteria,  599 
in  spinal  tumor,  747 
in  tuberculous  meningitis,  673 
Moral  insanity,  578 
Morbid  desires,  542 
fear,  forms  of,  539 
impulse,  539 
sleep,  661 
Morbilli.     See  Measles. 
Morphine  in  delirium  tremens,  561 
in  dengue,  200 
in  erysipelas,  403 
in  influenza,  195 
in  locomotor  ataxia,  787 


Morphine  in  pernicious  intermittent  fever, 
430 

in  Raynaud's  disease,  862 

in  relapsing  fever,  161 

in  scarlatina,  229 

in  sciatica,  849 

in  St.  Vitus's  dance,  632 

in  trichinosis,  511 

in  typhus  fever,  149 

in  yellow  fever,  4(K) 
Morphoea.     See  Scleroderma. 
Mortality,  calculation  of,  4 

in  various  occupations,  25 

general,  during  epidemics  of  influenza, 
192 
Mortality  of  anthrax,  482 

of  cerebro-spinal  fever,  179 

of  cholera,  446 

of  diphtheria,  388 

of  influenza,  193 

of  malarial  fevers,  430 

of  measles,  251 

of  rubella,  259 

of  small-pox,  280 

of  typhoid  fever,  109 

of  typhus  fever,  145 

of  whooping  cough,  319 

of  yellow  fever,  458 
Morvan's  disease,  775 

diagnosis  of,  from  svringomvelia, 
775 
Motor  area,  tumors  of,  719 
Motor  centres,  696 

destructive  lesions  of,  698 
irritative  lesions  of,  699 
Motor  centres  and  tracts,  lesions  of,  698 
Mottling  of  surface  in  cerebro-spinal  fever, 
174 

in  typhoid  fever,  72 

in  typhus  fever,  138 
Mountain  fever,  207 

Mouth-to-mouth  breathing,  tuberculous  in- 
fection by,  329 
Mucous  form  of  typhoid  fever,  102 
Mucous  membranes,  lesions  of,  in  scrofula, 

339 
Mucous  patches  in  acquired  syphilis,  353 

in  hereditary  syphilis,  363 
Mulberry  tongue,  217 
Multiple  neuritis.     See  Neuritis,  Multiple. 
Mumps,  304 

age  and  sex  in  etiology  of,  305 

complications  of,  308 

contagiousness  of,  305 

definition  of,  304 

diagnosis  of,  309 

etiology  of,  304 

immunity  conferred  by,  307 

morbid  anatomy  of,  306 

period  of  incubation  in,  307 

symptomatology  of,  307 

synonyms  of,  304 

treatment  of,  310 
Murmurs,  neurotic,  in  St.  Vitus's  dance,  631 
Muscle  callus  in  sterno-mastoid  in  infants, 
838 


lynEX. 


893 


Muscle  symptoms  in  trichinosis,  outi 
Muscles,  diseases  of,  850 

changes  in  Thomson's  disease,  857 

in  typhoid  fever,  64 
enlargement  of,  in  pseudo-hypertrophic 

muscular  atrophy,  853 
rupture  of,  in  tetanus,  407 
Musrular  crises  in  locomotor  ataxia,  779 
Muscular  dystrophies,  classification  of  851 
Muscular  sense,  testing  of,  528 
Musculo-sf)iral  paralysis,  843 
Myelitis,  acute,  752 

definition  of  752 
diagnosis  of,  756 
etiology  of,  752 
explosive,  755 
foudroyant  or  central,  755 
pathology  of,  752 
prognosis  of,  755 
symptomatology  of,  753 
treatment  of,  756 
trophic  changes  in,  755 
Myelitis,  acute,  diagnosis  of,  from  acute  as- 
cending paralysis,  756 

fn^n  multiple  peripheral  neu- 
ritis, 756 
Myelitis,  chronic,  758 

definition  of,  758 
diagnosis  of,  760 
etiology  of,  758 
patliology  of,  759 
prognosis  of  760 
.symptomatology  of,  759 
treatment  of,  760 
Myelitis,  subacute,  755 
Myocarditis  in  tvphoid  fever,  65,  93 
Myositis,  850 

acute     purulent,     following     typhoid 
fever,  850 
Myositis  ossificans  progressiva,  851 
Myotomy  in  torticollis,  839 
Myotonia  congenit;i.     See    Thomsen's  Dis- 
ease. 
Mvotonic  reaction    in    Thomsen's   disease, 

857 
Myxoedema,  relation  of,  to  acromegaly,  864 
diagnosis  of,  from  acromegaly,  864 

"VfAILS  in  acroniegaly,  863 

J^\    in  osteo-arthropatliic  piiciiiiii(|ii('.  864 

in  sclerodactyle,  S(J4 

in  small-pox,  271 

in  accjuircd  sypliilis,  353 
Naj)hthaiiii  in  typhoid  fever,  125,  127,  130 
Narcolepsy,  662 
Nasal  di[)htheria,  382 
Necrosis  from  phosphorus,  26 

in  acfiuircd  sy|)hilis,  352 

of  tibia  following  typhoid  fever,  90 
Negro,  small -pox  in  the,  263 

yellow  fever  in  the,  453 
Nelavan,  symptomatology  of,  661 
Nephritis  in  cerebro-spitial  fever,  166 

in  cholera,  441 

in  diphtheria,  383 

in  erysij)elas,  4<H) 


Nephritis  in  influenza,  194 
in  measles,  247 
in  relajising  fever,  158 
in  scarlatina,  218 
in  typhoid  fever,  97 
in  typhus  fever,  143 
in  yellow  fever,  456 
Nephritis,  influence  of,  upon  tvphoid  fever, 

112 
Nerve,  lesions  of  anterior  crural,  846 
of  auditory,  833 
of  circumflex,  843 
of  external  popliteal,  847 
of  facial,  827 
of  fifth,  824 
of  fourth,  821 
of  glosso-pharyngeal,  834 
of  hypoglossal,  839 
of  ilio-inguinal,  846 
of  internal  j)opliteal,  847 
of  long  thoracic,  843 
of  median,  844 
of  musculo-spiral,  843 
of  obturator,  846 
of  olfactory,  813 
of  optic,  813 
of  phrenic,  840 
of  pneumogastric,  835 
of  sciatic,  846 
of  sixth,  821 
of  spinal  accessorv.  837 
of  third,  819 
of  ulnar,  844 
Nerve-root  symptoms,  747 
Nerve-stretching  in  locomotor  ataxia,  789 
in  sciatica,  849 
in  torticollis,  839 
Nerves,   degeneration      of,     in     locomotor 
ataxia,  777 

in  typhoid  fever,  67 
Nerves,  diseases  of,  805 
of  cranial,  813 
of  spinal,  840 
Nervous  diseases,  general  svmptomatology 
,  of,  523 

'  Nervous  form  of  influen/a,  18it 
\  of  typhoid  fever,  98 

Nervous  symptoms  in  small-pox,  2()7 

ill  acute  miliary  tuberculosis,  333 
in  typhoid  fever,  7H 
in  yellow  lever,  455 
Neuralgia  of  nerves  of  feet,  847 
following  influenza,  192 
intercostal,  H45 
iiiiiibar,  S46 
occipito-ccrvical,  H40 
jieriodical,  in  malarial  fever,  417 
trifacial.  K26 

following  typhoid  fever,  i'l 
Neurasthenia,  587 
(lefiiiitioii  of,  587 
ele<'trieily  in,  591 
etiology  of,  587 
ma.ssag<'  in,  592 
rest  treatment  in,  590 
sviiiptoiiuifology  of,  587 


894 


INDEX. 


Neurasthenia,  traumatic,  642 

treatment  of,  589 
Neuritis,  brachial,  842 
Neuritis,  localized,  805 
etiology  of,  805 
morbid  anatomy  of,  805 
symptomatology  of,  806 
Neuritis,  multiple,  806 
alcoholic,  808 
diagnosis  of,  810 
endemic,  809 
etiology  of,  806 
morbid  anatomy  of,  807 
post-febrile,  809 
prognosis  of,  811 
symptomatology  of,  807 
treatment  of,  811 
Neuritis,  multiple,  diagnosis  of,  from  loco- 
motor ataxia,  785,  811 
from  acute  myelitis,  756 
from  acute  poliomyelitis,  768, 

810 
from  syringomyelia,  775 
Neuritis  in  cerebro-spinal  fever,  167 
in  diphtheria,  384 

in  etiology  of  facial  hemiatrophy,  867 
optic,  815 

in  symmetrical  gangrene,  861 
in  typhoid  fever,  ■Ql 
Neuro-glioma,  717 
Neuroma,  812 
cellulare,  812 
false,  812 
plexiform,  812 
true,  812 
Neuropathic  insanities,  547 
Neuropathic  insanity,  575 

prognosis  and  treatment  of,  579 
Neuroses,  occupation,  651 
traumatic,  642 
treatment  of,  642 
Neurotomy  in  torticollis,  839 
Night  in  etiology  of  malarial  fever,  411 

of  yellow  fever,  453 
Night-blindness,  815 
Night-palsy,  663 
Night-terrors  in  children,  664 
Nitrate  of  silver  in  ephemeral  fever,  50 
in  small-pox,  282 
in  typhoid  fever,  125,  128,  129 
Nitrite  of  amyl  in  epilepsy,  623 

in  hiccough,  841 
Nitro-glvcerin  in  neuralgia  of  fifth  nerve, 
827 
in  typhoid  fever,  132 
Nitro-muriatic  acid  in  typhoid  fever,  126 

in  typhus  fever,  149 
Nocturnal  epilepsy,  616 
Noma  in  measles,  244 
Nux  vomica  in  typhoid  fever,  125 
Nyctalopia,  815 
Nystagmus,  824 

in  cerel)ro-spinal  fever,  173 
in  chronic  hydrocephalus,  724 
in  coal-miners,  824 
in  Friedreich's  ataxia,  798 


Nystagmus  in  insular  sclerosis,  712 
in  trichiiKJsis,  506 

in  tumors  of  the  corpora  quadrigemina, 
721 
Nvstagmus,  ataxic,  in  Friedreich's  ataxia, 
798 
static,  in  Friedreich's  ataxia,  798 

OBERMEIEE,  spirillum  of,  151 
Obesity  following  typhoid  fever,  90 
Obturator  nerve,  affections  of,  846 
Occipital  lobe,  tumors  of,  720 
Occipito-cervical  neuralgia,  840 
Occlusive  meningitis.    See  Leptomeningitis. 
Occupation  neuroses,  651 
etiology  of,  651 
pathology  of,  651 
prognosis  of,  653 
symptomatology  of,  651 
treatment  of,  653 
Occupations,  mortality  of  the  various,  25 
Ocular  complications  in  small-pox,  277 
Ocular  paralyses  in  diphtheria,  384 
Ocular  symptoms  in  ataxic  paraplegia,  794 
in  brain  syphilis,  727,  729 
in  Friedreich's  ataxia,  798 
in  insular  sclerosis,  712 
in  locomotor  ataxia,  781 
in  meningitis,  674 
in  migraine,  658 
in  chronic  periencephalitis,  553 
in  tuberculous  meningitis,  672 
in  typhoid  fever,  80 
Odor  of  patient  in  typhoid  fever,  72 

of  stools  in  typhoid  fever,  84 
Oedema  in  angio-neurotic  oedema,  862 
in  anthrax,  481 
in  erysipelas,  399 
in  local  asphyxia,  859 
in  multiple  endemic  neuritis,  809 
in  scarlatina,  219 
in  small-pox,  280 
in  trichinosis,  505 
(Edema  of  the  brain,  678 

in  cerebro-spinal  fever,  167 
in  typhoid  fever,  66 
CEdema   of  the   larynx    in   angio-neurotic 
oedema,  802 

in  erysipelas,  400 
in  scarlatina,  224 
in  typhoid  fever,  66,  95 
CEdema  of  the  lungs  in  influenza,  189 

in  paralysis  of  the  diaphragm,  841 
in  scarlatina,  224 
in  typhoid  fever,  95,  132 
CEsophagismus  in  hysteria,  602 
CEsophagitis  in  typhoid  fever,  91 
Oleo-margarine,  23 
Oleum  morrhufe.     See  Cod-liver  Oil. 
Olfaction,  tests  of  813 
Olfactory  aurae  in  epilepsy,  615 
Olfactory  nerve,  affections  of,  813 
Omentum,  tubercles  in,  in  acute  miliary  tu- 
berculosis, 331 
Ophthalmoplegia,  823 
externa,  823 


INDEX. 


895 


Ophthalmoplegia  interna,  823 

l)r()gressiva    in    proirressive    muscular 
atrophy,  803 
Opisthotonos  in  cerebro-spinal  fever,  172 
in  hysteria,  596 

in  leptomeningitis  infantum,  G7G 
in  meningitis,  tj74 
in  scarlatina,  224 
in  tetanus,  467 
Opium  in  eerebro-spinal  fever,  182 
in  influenza,  195 
in  measles,  252 
in  melancholia,  567 
in  migraine,  659 
in  relapsing  fever,  161 
in  tetanus,  470 
in  tvphoid  fever,   125,   127,   128,  129, 

130,  131 
in  typhus  fever,  149 
in  whooping  cough,  320 
Opium-poisoning,  diagnosis  of,  from  cere- 
bral haemorrhage,  686 
Optic  atrophy  in  acromegaly,  864 
in  brain  tumor,  719 
in  locomotor  ataxia,  782 
primary,  816 
secondary,  816 
Optic  chiasma,  affections  of,  818 
nerve,  affections  of,  815 
tract,  affections  of,  818 
Optic  neuritis,  815 

in  brain  abscess,  715 
in  brain  tumor,  719 
in  cerebro-spinal  fever,  173 
in  tuberculous  meningitis,  673 
Optic  thalamus,  tumors  of,  721 
Orchitis  in  mum|)s,  308 

in  typhoid  fever,  66,  97 
Organic  epilepsy.     See  Epilepay. 
Organic  insanities,  548 
Oriental  plague,  cause  of,  12 
Orthotonos  in  cerebro-spinal  fever,  168 

in  tetanus,  467 
Ossifying  myositis,  851 
Osteitis  deformans,  diagnosis  of,  from  acro- 
megaly, 864 
Osteo-arthropathie  pneumique,  864 
Osteo-myelitis  in  hereditary  syphilis,  364 
Otitis  media  in  cerebro-spinal  fever,  174 
in  diphtheria,  382 
in  measles,  248 
in  relapsing  fever,  158 
in  scarlatina,  217 
Otorrha'a  in  typhoid  fever,  91 
Oxalic  acid  as  a  gennicidt',  20 
Oxygen  in  typlioiil  fever,  132 
Oziena  in  acquired  sy|)liilis,  352 
in  hereditary  syphilis,  363 

PACHYMENINGITIS,   cervical,    diag- 
nosis of,  from  syringomyelia,  775 
externa,  669 

symptomatology  of,  669 
hfemorrhagica,  66!* 

morbid    anatomy    and    i)athology 
of,  669 


Pachymeningitis  hpemorrhagica,  symptom- 
atology of,  670 

interna,  669 

acute  spinal,  741 
Paget's  disease.     See  Osteiti*  Deformans. 
Pain  in  anthrax,  481 

in  bilious  intermittent  fever,  426 

in  brain  syphilis,  728 

in  brain  tumors,  718 

in  diphtheria,  381 

in  erysipela.s,  398 

in  influenza,  187 

in  localized  neuritis,  806 

in  loc()in(>t()r  ataxia,  778 

in  multiple  neuritis,  807 

in  mumps,  307 

in  acute  myelitis,  754 

in  myositis,  850 

in  nerve  syphilis,  736 

in  sciatica,  848 

in  small-pox,  267 

in  acute  spinal  meningitis,  742 

in  .spinal  tumors,  748 

in  symmetrical  gangrene,  860 

in  tetanus,  467 

in  tertiary  syphilis,  353 

in  trichinosis,  506.  507 

in  typhoid  fever,  81 

in  typhus  fever,  140 
Pain  crises  in  locomotor  ataxia,  778 
Painters,  mortality  of,  26 
Palate,  paralysis  of,  in  diphtheria,  384 
in  facial  paralysis,  830 

syphilitic  scars  of,  355 
Palmar  reflex,  525 

Palpitation   of  the  heart  in  cerebro-spinal 
fever,  175 

in  hysteria,  601 
in  typhoid  fever,  85 
Paludism.     See  Malarial  Fcvera. 
Pancreas,  changes  in,  in  hereditarv  svphilis, 

364 
Pancreatin  in  iliplitheria,  392 
Panophthalmitis  in  scarlatina,  223 

in  snu\ll-pox,  277 
Papayotin  in  diphtheria,  392 
Paper-makers,  mortal  it  v  of,  2(5 
Papillitis,  815 

Paradoxical  contractions,  definition  of,  525 
Pariesthesia  in  antero-lateral  sclero.sis,  791 

in  hysteria,  599 

in  locomotor  ataxia,  780 

in  neuritis,  806,  807,  808 

in  syringomyelia,  773 

in  trichinosis,  5((6 
Paragcnsis,  83.') 
Paralyses  in  acute  miliary  tuberculosis,  333 

in  tuberculosis  meningitis,  673 
Paralysis  of  abductors,  836 

of  adduction,  .S36 

in  acute  ascending  paralysis,  749 

atrophic,  772 

of  brachial  olexus,  841 

in  brain  sypliilis,  729 

in  iiriiin  tumor,  720 

in  canine  hydrophobia,  487 


896 


INDEX. 


Paralysis  in  cerebral  embolism  and  throm- 
bosis, 690 
in  cerebral  haemorrhage,  682 
cerebral  infantile,  706 

treatment  of,  710.     See,  also, 
Htmipleyia,  Infantile,  Diple- 
gia, Spastic,  and  Paraplegia, 
Infantile  Spastic. 
in  cerebro-spinal  fever,  173 
circumflex,  843 
crutch,  843 
of  diaphragm,  840 
in  diphtheria,  peculiarities  of,  384 
following  dislocation  of  humerus,  841 
facial,  827 
of  fifth  nerve,  824 
of  fourth  nerve,  821 
in  glosso-labial  paralysis,  803 
of  glosso- pharyngeal  nerve,  834 
of  heart  in  diphtheria,  384 
of  hypoglossal  nerve,  839 
in  hysteria,  599 

pecailiarities  of,  603 
infantile,  761 
Landry's,  748 

of  long  thoracic  nerve,  843 
of  median  nerve,  844 
of  motor  nerves  of  eye,  822 

diplopia  in,  823 

erroneous  projection  in,  823 

ophthalmoplegia  in,  823 

secondary  deviation  in,  822 

strabismus  in,  822 

treatment  of,  824 
in  multiple  neuritis,  807 
in  multiple  alcoholic  neuritis,  808 
musculo-spiral,  843 
in  acute  myelitis,  754 
obstetrical,  842 
olfactory,  813 

of  pneumogastric  nerve,  835 
in  acute  poliomyelitis,  764 
in  subacute  poliomyelitis,  771 
in  progressive  muscular  atro])liv,  800 
radial,  843 

of  recurrent  laryngeal  nerve,  836 
sciatic,  846 
serratus,  843 
of  sixth  nerve,  821 
of  spinal  accessory  nerve,  837 
in  syringomyelia,  774 
of  third  nerve,  819 
in  typhoid  fever,  91 
of  ulnar  nerve,  844 
of  vocal  cords,  836 
Paralysis  agitans,  639 

symptomatology  of,  639 

treatment  of,  641 
Paralysis,  general,  definition  of,  523 
local,  definition  of,  523 
multiple,  definition  of,  523 
Paramyoclonus  multij)lex,  857 

etiology  of,  857 

symptomatology  of,  857 
Paranoia,  579 

definition  of,  579 


Paranoia,  delusions  in,  581 

diagnosis  of,  583 

of  early  development,  580 

etiology  of,  579 

hallucinations  in,  582 

of  late  development,  581 

symptomatology  of,  580 
Paraphasia,  704 
Paraplegia,  definition  of,  523 
Paraplegia  in  acute  ascending  paralysis,  749 

in  antero-lateral  sclerosis,  790 

in  hysteria,  599 

in  multiple  neuritis,  809 

in  multiple  alcoholic  neuritis,  808 

in  acute  myelitis,  754 

in  chronic  myelitis,  760 

in  spinal  ansemia,  744 

in  spinal  apoplexy,  746 

in  spinal  tumor,  747 

in  syringomyelia,  774 
Paraplegia,  infantile  spastic,  710 
Parietal  lobe,  tumors  of,  720 
Paronychise  in  small-pox,  271 
Parosmia,  etiologv  of,  813 
Parotid  bubo,  309 
Parotitis  in  cerebro-spinal  fever,  176 

in  relapsing  fever,  157 

in  typhoid  i'ever,  66,  91 

in  typhus  fever,  145 
Parotitis,  metastatic,  309 
Paroxysm  in  hydrophobia,  493 

in  intermittent  fever,  413 

in  melancholia,  564 

in  spinal  neurasthenia,  643 

in  whooping  cough,  315 

in  yellow  fever,  455 
Paroxysmal      hsemoglobinuria    and    Ray- 
naud's disease,  861 
Pasteur's  method.     See  Hydrophnbia. 
Patellar  reflex,  525.     See,  also.  Knee-jerk. 
Pemphigus  in  cerebro-spinal  fever,  174 

in  hereditary  syphilis,  363 
Pepsin  in  typhoid  fever,  129 
Peptonized  milk  in  typhoid  fever,  115 
Peptonoids  in  typhoid  fever,  128 
Peptonuria    in  acute  miliary  tuberculosis, 

332 
Perforating  ulcer  in  anaesthetic  leprosy,  371 

in  locomotor  ataxia,  783 
Perforation   of  intestine  in  tvphoid  fever, 

92 
Pericarditis  in  cerebro-spinal  fever,  176 

in  dengue,  199 

in  influenza,  190 

in  scarlatina,  224 

in  typhoid  fever,  93 
Perichondritis  in  hereditary  syphilis,  364 
Periencephalitis,  acute,  548 

definition  of,  548 

diagnosis  of,  549 

etiology  of,  548 

pathology  of,  548 

jjrognosis  of,  550 

symptomatology  of,  548 

synonyms  of,  548 

treatment  of,  550 


IXDEX. 


897 


Periencephalitis,  acute,  diagnosis  of,  from 

pneumonia,  549 
Periencephalitis,  chronic,  550 
definition  of,  55(1 
diagnosis  of,  55G 
etiology  of,  550 
pathology  of,  551 
prognosis  of,  556 
symptomatology  of,  551 
synonyms  of,  550 
treatment  of,  556 
types  of,  552 
Period   of  incubation    in  tetanus,  relation 

of,  to  prognosis,  469 
Periodic  amnesia,  667 
Periodical  insanity,  584 
definition  of,  5<S4 
symptomatology  of,  585 
types  of,  584 
Periodical  melancholia,  586 
Periodicity  in  angio-neurotlc  oedenui,  862 

in  local  asphyxia,  860 
Periosteal  nodes  in  acijuired  syphilis,  352 
Periostitis  in  hereditary  syphilis,  364 

following  typhoid  fever,  90 
Peripheral  neuritis.    See  Neuritis,  Multiple. 
Peritoneum,  tubercles  in,  in  acute  miliary 

tuberculosis,  331 
Peritonitis  in  relapsing  fever,  153 
in  scarlatina,  225 
in  typhoid  fever,  93,  130 
Permanganate  of  notassium  as  germicide, 

20 
Pernicious  intermittent  fever.     See  Mala- 

rinl  Fever!i. 
Peroneal  type  of  muscular  atrophy,  856 
Peroxide  of  hydrogen  as  germicide,  20 
Personal  identity,  sense  of,  667 
Pertussis.     See   Wkooping  Coiiyh. 
Petechise  in  cerebro-spinal  fever,  174 
in  measles,  244 
in  small-pox,  268 
in  typhoid  fever,  72 
in  typhus  fever,  144 
Petit  mal,  615 

Peyer's   patches,    changes    in,    in    typhoid 
fever,  61 
in  tvphus  fever,  137 
Pfeiffer's  bacillus,  185 
Phantom  tumor,  604 
Pharyngitis  in  typhoid  fever,  82,  91 
I'harynx,  paralysis  of  muscles  of,  836 

spasm  of  muscles  of,  836 
Phenacetin  in  cerebro-spinal  fever,  183 
in  dengue,  200 
in  ephemeral  fever,  50 
in  influenza,  194,  195 
in  locomotor  ataxia,  787 
in  scarlatina,  228 
in  small-pox,  282 
in  typhoid  fever,  123,  127 
I'hiebitis  in  typhoid  fever,  78 
Phlegmasia  in  typiioiil  fever,  93 
I'hicgiiiiitic  tyj)e  of  scrofula,  340 
Phospiiates  in  urine  in   confusionul  insan- 
ity, 571 
Vol,.  \.—'.>l 


Phosphoric  acid  in  typhoid  fever,  116,  126 

in  typhus  fJver,  149 
Phosphorus  in  confusioual  insanity,  574 
Phosphorus-j)oisoiiing,  211 
IMiotophobia  in  hysteria,  600 

in  measles,  247 
Phrenic  nerve,  affections  of,  840 
Phthisis  from  inhalation  of  dust,  26 
following  influenza,  190 
relation  of,  to  malarial  fever,  412 
following  typhoid  fever,  97 
Physicians,  mortality  of,  26 
Phvsiological  test  in  diajrnosis  of  anthra.x, 

482 
Pia  mater,  diseases  of,  670 
Pigmentation  of  organs  in  remittent  mala- 
rial fever,  423 
of  skin  in  scleroderma,  .^65 
Pitting  in  small-pox,  prevention  of,  282 
Pituitary    body,    enlargement    of,   in  acro- 
megaly, >^Q>\ 
Placenta,  changes  in,  in  syphilis,  362 
Plantar  rellex,  524 
Plaques  jaunes,  690 
Plasmodium  malaria",  407 
in  soil,  29 
in  water,  30 
Pleurisy  in  cerebro-spinal  fever.  176 
in  influenza,  190 

osteo-arthro)iathie  pneumiijue  in  puru- 
lent, 864 
in  relapsing  fever,  157 
in  scarlatina,  224 
in  typhoid  fever,  95,  99 
in  typhus  fever,  137 
Pieurosthotonos  in  tetanus,  467 
Plexiform  neuroma,  812 
Plumbers,  mortality  of,  26 
Pneumogastric  nerve,  cardiac  branches 
836 
functions  and  lesions  of,  835 
gastric;  and   (esophageal   bram 

of,  837 
involvement  of,  in  inlhienza,  !;•: 
laryngeal  branches  of,  836 
pharyngeal  branches  of,  S.Sii 
pulmonary  brani'hes  of,  836 
Pneumonia  in  (•ereliro-s))inal  fever,  176 
in  inHut-nza.  1X9,  190 
in  measles,  246 
in  rehijising  fever.  157 
in  .scarlatina,  224 
in  typhoid  fever,  95,  98,  132 
in  typhus  fever,  1  M 
Pneumonia,    tliatrnosis    of,    from     m;il;tii 
fever,  419 
from  acuti'  perienei  pliaiilis.  519 
Pododynia,  S47 

Polio-eneeplialitis  superior  acuta.  S2  t 
J'oliomyelitis,  acute,  7<»1 
(lefinitioti  of,  761 
diagnosis  of.  767 
elioir»gy  of,  761 
pathology  of,  762 
prognosis  o(",  76M 
symplonnitology  <»f,  76;{ 


of. 


les 


898 


INDEX. 


Poliomyelitis,  acute,  synonyms  of,  761 

treatment  of,  769 
Poliomyelitis,  acute,  diagnosis  of,  from  acute 
ascending  paralysis,  768 

from  multiple  neuritis,  768, 810 
Poliomyelitis,  subacute,  771 

treatment  of,  771 
Poliomyelitis,  subacute,  diagnosis  of,  from 
pseudo-hypertrophic  muscular  atro- 
phy, 855 

from  subacute  metallic  polio- 
myelitis, 772 
Poliomyelitis,  subacute  metallic,  772 

diagnosis  of,  772 
Polysesthesia  in  locomotor  ataxia,  780 
Polymyositis,  diagnosis  of,  from  trichinosis, 

509 
Polyneuritis.     See  Neuritis,  Multiple. 
Polyuria  in  brain  syphilis,  729 
in  cerebro-spinal  fever,  176 
in  hysteria,  602 
Pons,  lesions  of,  701 

tumors  of,  721 
Popliteal  nerve,  external,  atfections  of,  847 

internal,  affections  of,  847 
Population,  calculation  of,  4 
Porencephalus,  707 
Position  test,  527 

Posterior  meningitis.     See  Leptomeningitis. 
Posterior  sclerosis.     See  Locomotor  Ataxia. 
Post-febrile     polyneuritis.      See    Neuritis, 

Multiple. 
Post-hemiplegic  movements,  708 
Post-mortem  elevation  of  temperature  in 
cholera,  443 

in  tetanus,  467 
Post-mortem  movements  in  cholera,  443 
Potassium  bromide.     See  Bromides. 
chlorate  in  diphtheria,  391 
citrate  in  typhoid  fever,  124 
iodide.     See  Iodide  of  Potassium. 
Predisposing  causes  of  disease,  7 
Prefrontal  area,  tumors  of,  720 
Pregnancy  and  chorea,  633 
Prehemiplegic  chorea,  682 
Pressure  sense,  testing  of  the,  528 
Priapism  in  acute  myelitis,  754 
Primarv  atrophic  form  of  muscular  atrophy, 

854 
Primary  curable  dementia.    See  Confusional 

Lisauitii. 
Printers,  mortality  of,  26 
Prison-cells,  dimensions  of,  39 
Progressive  muscular  atrophy,  799 
definition  of,  799 
diagnosis  of,  804 
etiology  of,  799 
pathology  of,  799 
prognosis  of,  804 
symptomatology  of,  800 
synonyms  of.  799 
treatment  of,  804 
Progressive  myopathic  atrophy,  852 
Propeptone  in  urine  in  measles,  247 
Prophylaxis  of  actinomycosis,  477 
of  anthrax,  482 


Prophylaxis  of  cerebro-spinal  fever,  180 

of  cholera,  446 

of  diphtheria,  388 

of  erysipelas,  402 

of  foot-and-mouth  disease,  622 

of  glanders,  517 

of  hydrophobia,  497 

of  leprosy,  372 

of  malarial  fevers,  419 

of  measles,  251 

of  relapsing  fever,  160 

of  scarlatina,  225 

of  scrofula,  342 

of  syphilis,  356 

of  tetanus,  469 

of  trichinosis,  510 

of  typhoid  fever,  113 

of  typhus  fever,  147 

of  varicella,  302 

of  yellow  fever,  459 
Prosopalgia,  826 

Pseudo-angina  pectoris  in  hysteria,  601 
Pseudo-diphtheria,  376 
Pseudo-hallucinations,  534 
Pseudo-hypertrophic  muscular  atrophy,  853 

symptomatology  of,  853 
Pseudo-hypertrophic     muscular     atrophy, 
diagnosis   of,   from   subacute   polio- 
myelitis, 855 
Pseudo-paralytic  rigidity,  710 
Psychical  antestliesia,  563 

dysthesia,  563 

hypersesthesia,  563 
Ptomaines  in  diphtheria,  375 

in  typhoid  fever,  58 
Ptosis,  causes  of,  820 

forms  of,  820 

hysterical,  820 

in  locomotor  ataxia,  782 

pseudo-,  820 
Puerperal  scarlatina,  210 
Pulmonary  form  of  typhoid  fever,  98,  106 

gangrene  in  typhoid  fever,  95 

haemorrhage  in  high  altitudes,  27 

veins,  spread  of  tuberculosis  from,  330 
Pulse  in  cerebral  haemorrhage,  682 

in  cerebral  tumor,  719 

in  cerebro-spinal  fever,  175 

in  cholera,  442,  443 

in  dengue,  198 

in  diphtheria,  381,  384 

in  epilepsy,  614 

in  hysteria,  601 

in  intermittent  fever,  414 

in  meningitis,  675 

in  miliary  fever,  202 

in  pneumogastric  paralysis,  837 

in  relapsing  fever,  155 

in  small-pox,  266 

in  tetanus,  467 

in  acute  miliary  tuberculosis,  332 

in  tuberculous  meningitis,  672 

in  typhoid  fever,  87 

in  typhus  fever,  141 

in  yellow  fever,  455,  456 
Pupillary  inaction,  hemiopic,  818 


IXDhX. 


899 


Pupils  in  cerebral  hfcmorrhajre,  682 

in  cerebro-spinal  lever,  173 

in  the  epileptic  paroxysm,  613 

in  hysteria,  594 

in  locomotor  ataxia,  782 

in  chronic  periencephalitis,  553 

in  typhoid  fever,  80 

in  typhus  fever,  139 
Pupils,  unequal,  821 

in  hysteria,  599 
Pure  insanities,  562 
Purpura  in  cerebro-spinal  fever,  109 

in  iueniaturic  intermittent  fever,  427 

in  relapsing  fever,  155 

variolosa,  274 
Pustule  maligiie.     See  Anthrar. 
Pytemia,  326" 

abscesses  in,  327 

definition  of,  326 

diagnosis  of,  328 

idiopathic,  326 

micro-organisms  in,  326 

pathology  of,  328 

prognosis  of,  328 

pulmonary,    following   thrombosis    of 
cerebral  sinuses,  695 

symptomatology  of,  327 

treatment  of,  328 
Pyaemia,  diagnosis  of,  from  malarial  fever, 
328,  419,  429 

from  scarlatina,  222 
from  typhoid  fever,  328 
Pysemic  rheumatism,  328 
Pyelitis  in  typhoid  fever,  66,  97 
Pyramidal  tract,  course  of,  697 
Pyromania,  585 

QUARANTINE,  21 
against  cholera,  450 

against  yellow  fever,  460 
Quarrymen,  mortality  of,  26 
(Quartan  malarial  fever,  405 
Quinine  in  cerebro-spinal  fever,  182 

in  dengue,  200 

in  ephemeral  fever,  50 

in  influenza.  194 

in  malarial  fevers,  421,  425,  430,  432 

in  miliary  fever,  203 

in  mountain  fever,  207 

in  pyu'inia,  328 

in  relapsJMir  fever,  160 

in  typhoid  fever,  123,  127,  132 

in  typhus  fever,  149 
f      Quotidian  malarial  fever,  405 

RAIUES.     8ee  H;idrnphohi<i. 
Race  in  etiology  of  hysteria,  593 
of  malarial  fevers,  410 
of  yellow  fever,  453 
of  syphilis,  346 
Rachitis,  diagnosis  of,  from  chronic  hydro- 
cei)Iialus.  724 
from  liercditary  syphilis,  366 
Radial  [laralysis,  843 
Railway  spine.     See  S'pintil  NeuroHtkniia. 
Riles  in  influenza,  188 


Rrdes  in  typhoid  fever,  88 

Rashes.     See  Eruptions. 

Ray  fungus  in  etiology  of  actinomycosis, 

473 
Raynaud's  disease,  859 

definition  of,  859 
pathology  of,  861 
prognosis  of,  861 
treatment  of,  862 
varieties  of,  859 
Reaction  stage  in  cholera,  444 
Reactions  of  degeneration,  764 

in  diphtheritic  paralysis,  384 
in  Friedreich's  ataxia,  798 
in  multiple  neuritis,  S07 

alcoholic  neuritis,  808 
in  acute  myelitis,  755 
in     peroneal    type    of    muscular 

atrophy,  856 
in  acute  poliomyelitis,  764 
in  progressive  nuiseular  atrophy, 

802 
in  spinal  muscular  atrophy, •855 
electrical,     in      idiopathic      muscular 
atrophy,  855 
in  localized  neuritis,  806 
in  Thomsen's  disease,  857 
Reasoning  insanity,  578 
Recrudescences  in  typhoid  fever,  78.  104 
Rectal  crises  in  locomotor  ataxia,  779 
Rectum,  paralysis  of.     See  Sijliinctens,  Fa- 

ralyxis  of. 
Red  softening  of  the  brain,  689 
Reflex  chorea,  633 

of  pregnancy,  633 
treatment  of,  633 
Reflex  epilepsy.     See  Epi/epn;/. 
Reflex  iridojilegia,  821 

in  locomotor  ataxia,  782 
Reflexes  in  acute  ascending  paralysis,  749 
in  amyotrojihic  lateral  sclerosis.  794 
in  antero-lateral  sclerosis,  791 
in  ataxic  paraplegia,  794 
in  diphtheritic  paralysis,  384 
in  hemiplegia,  ()8(),  708 
in  hysterical  i)araplegia,  599 
in  idiopathic!  muscular  atrophy,  855 
in  infantile  hemiplegia,  70S 
in  insular  sclerosis,  712 
in  locomotor  ataxia,  7N0 
in  multiple  neuritis,  8tl7 
in  multiple  alcoholic  neuritis,  808 
in  acute  myelitis,  754 
in  chronic  myelitis.  760 
in  acute  poli<imyelilis,  764 
in  progressive  muscular  atrophy,  803 
in  acute  spinal  meningitis,  742 
in  chronic  spinal  meningitis,  743 
in  spinal  syphilis,  734 
in  spinal  tumor,  747 
in  Thomsen's  disease,  857 
Keflex. 's,  524 
deep,  525 
superficial,  524 
Reinfiction  in  erysipelas,  400 
in  typlwdd  fever,  105 


900 


INDEX. 


Relapses  in  cerebro-spinal  fever,  177 
in  cholera,  444 
in  dengue,  197 
in  influenza,  186 
in  malarial  fever,  418 
in  relapsing  fever,  156 
in  scarlatina,  220 
in  typhoid  fever,  103 
in  typhus  fever,  146 
in  yellow  fever,  457 
Relapsing  fever,  150 

cause  of,  12,  151 
complications  of,  157 
definition  of,  150 
diagnosis  of,  159 
etiology  of,  150 
history  of,  150 
morbid  anatomy  of,  152 
prognosis  of,  160 
sequelfe  of,  157 
symptomatology  of,  154 
synonyms  of,  150 
treatment  of,  160 
Relapsing  fever,  diagnosis  of,  from  mala- 
rial fever,  159 
from  rheumatic  fever,  159 
from  typhoid  fever,  107,  159 
from  typhus  fever,  159 
from  yellow  fever,  458 
Remak's  contractions,  802 
Remittent   malarial    fever.      See    Malarial 

Fevem. 
Renal  form  of  typhoid  fever,  99,  102 
Respiration  in  cerebral  haemorrhage,  682 
in  dengue,  198 

in  the  epileptic  paroxysm,  614 
in  glosso-labial  paralysis,  804 
in  hysteria,  602 
in  small-pox,  266 
'  in  acute  miliary  tuberculosis,  333 
in  tuberculous  meningitis,  672 
in  typhoid  fever,  88 
in  typhus  fever,  142 
Rest-cure.     See  Red-treatment. 
Rest-treatment  in  hysteria,  606 
in  melancholia,  567 
in  neurasthenia,  590 
Retention  of  urine  in  cerebro-spinal  fever, 
176 
in  hysteria,  609 
in  locomotor  ataxia,  788 
in  acute  myelitis,  758 
in  typhoid  "fever,  89,  133 
Retina,  detachment   of,  in   cerebro-spinal 
fever,  167 
functional  disturbances  of,  815 
Retinal  hypersesthesia,  815 
Retinitis,  813 

albuminuric,  814 
leuksemic,  814 
Retraction  of  the  head  in  cerebro-spinal 
fever,  172 
in  leptomeningitis  infantum,  676 
in  typhoid  fever,  98 
in  typhus  fever,  146 
Revaccination,  295 


Rhagades  in  hereditary  syphilis,  363 
Rheumatic  fever,  diagnosis  of,  from  cere- 
bro-spinal fever,  179 
from  dengue,  199 
from  miliary  fever,  202 
from  relapsing  fever,  159 
from  acute  spinal  meningitis,  742 
from  trichinosis,  509  • 

Rheumatism,  pysemic,  328 
Rhinitis,  syphilitic,  365 
Rhinoscleroma,  cause  of,  12 
Rhythmical  contraction  in  paramyoclonus 

multiplex,  857 
Rice-water  stools,  441 
Rigidity  in  cerebro-spinal  fever,  168 
early,  in  hemiplegia,  683 
late,  in  hemiplegia,  685 
in  typhoid  fever,  82 
Rigor  mortis  in  cholera,  439 
Rigors.     See  Chills. 
Risus  sardonicus,  466 
Romberg's  symptom.     See  Knee-Jerk. 
Rooms,  currents  of  air  in,  40 
disinfection  of,  19 
proper  dimensions  of,  39 
Root-symptoms,  747 

Root-zone,  posterior,  changes  in,  in  locomo- 
tor ataxia,  776 
Rotheln.     See  Rubella. 
Rubella,  254 

complications  and  sequelae  of,  258 
contagiousness  of,  255 
definition  of,  254 
diagnosis  of,  259 
eruption  in,  257 
etiology  of,  255 
affection  of  the  glands  in,  258 
period  of  incubation  in,  256 
prognosis  of,  259 
symptomatology  of,  256 
synonyms  of,  254 
treatment  of,  260 
Rubella,  diagnosis  of,  from  measles,  259 
from  scarlatina,  221,  259 
from  syphilis,  259 

Q  ACRAL  nerves,  affections  of,  S46 

lO     Salaam    convulsions.      See   Automatic 

Chorea. 
Salicin  in  relapsing  fever,  161 

in  typhoid  fever,  127 
Salicylates  in  acute  ascending  paralysis,  751 

in  dengue,  200 

in  influenza,  194 

in  relapsing  fever,  161 

in  multiple  neuritis,  811 

in  scarlatinal  rheumatism,  229 

in  sciatica,  849 

in  typhoid  fever,  127 
Salicylic  acid  in  relapsing  fever,  161 

in  typhoid  fever.  124 
Saline  injections,  subcutaneous,  in  cholera, 

448 
Salines  in  typhoid  fever,  130 

in  typhus  fever,  149 
Salivary  glands  in  typhoid  fever,  65 


INDEX. 


901 


Salivation  in  mercurialism,  358 
Salol  in  cholera,  449 

in  typhoid  fever,  125,  127 
Sanitary  jurisprudence,  43 
'Sarcoma  of  the  brain,  717 
Scanning  speech  in  insular  sclerosis,  712 
in  chronic  periencephalitis,  553 
Scapular  reflex,  525 
Scarlatina,  208 

in  animals,  213 

complications  of,  222 

contagiousness  of,  211 

definition  of,  208 

diagnosis  of,  221 

diphtheritic  patches  in,  217 

etiology  of,  209 

isolation  after,  21 

morbid  anatomy  of,  225 

in  the  new-born,  210 

})rognosis  of,  224 

prophylaxis  of,  225 

relation  of,  to  diphtheria,  214 

symptomatology  of,  214 

synonyms  of,  208 

treatment  of,  227 

varieties  of,  220 
Scarlatina,  dia«;nosis  of,  from  cerebro-spinal 
fever,  179 
from  diphtheria,  222,  387 
from  measles,  221 
from  septicaemia  and  pytemia,  222 
from  small-pox,  279 
from  rubella,  221,  259 
from  typhoid  fever,  108 
Scarlatinal  diphtheritis,  214 

nephritis,  218 

rheumatism,  218 
Scarlet  fever.     See  Scarfatina. 
School-rooms,  ventilation  of,  39 
Sciatic  nerve,  affections  of,  846 
Sciatica,  848 

diagnosis  of,  848 

symptoms  of,  848 

treatment  of,  849 
Sclerema  neonatorum,  866 
Sclerodactyle,  8G4 
Scleroderma,  865 

pathology  of,  865 

symptomatology  of,  865 

treatment  of,  866 
Sclerosis  of  brain,  diffuse,  miliary,  and  tu- 
berous, 713 

insular.     See  I/ixnlar  Scleroxls. 

lateral.     See  Antero-laternl  Sdcronis. 

posterior.     See  Locomofor  Ataxia. 
Scoliosis  in  syringomyelia,  774 
Scrivener's  ))alsy.    See  Occupation  Neuroses. 
Scrofula,  336 

acfjuired,  336 

bone  lesions  in,  340 

complications  ami  terminations  of,  341 

course  iitid  diiralion  of,  341 

definition  of,  336 

diagnosis  of,  342 

erethitic  type  of,  340 

etiology  of,  336 


Scrofula,  heredity  in  etiology  of.  336 
lymphatic  glands  in,  338 
morbid  anatomy  of,  338 
mucous-membrane  lesions  in,  339 
phlegmatic  type  of,  340 
prognosis  of,  342 
prophylaxis  of,  342 
relation  of,  to  tuberculosis,  337 
skin  lesions  in,  340 
symptomatology  of,  340 
synonyms  of,  33t) 
treatment  of,  342 
Scrofula,  diagnosis  of,  from  syphilis,  342 
Setuson  in  etiology  of  cerebro-spinal  fever,  164 
of  cholera,  f35 
of  <li|)litlieria,  378 
of  influenza,  1S6 
of  malarial  fevers,  410 
of  measles,  233 
of  milk  sickness,  204 
of  relapsing  fever,  151 
of  typhoid  fever,  53 
of  typhus  fever,  135 
of  yellow  fever,  452 
Secondary  deviation,  822 
Secondary  fever  in  small-pox,  272 

in  typhoid  fever,  74 
Senile  chorea,  634 

Sensation,  delayed,  in  locomotor  ataxia,  780 
disturbances  of,  in  hysteria,  599 
painful,  loss  of,  in  hysteria,  600 

and  thermic,   loss  of,   in  syringo- 
myelia, 773 
tests  for,  527 
varieties  of,  529 
Sense-shock,  663 

Sense  of  taste,  disturbances  of,  835 
Sensory  aphasia.     See  Aphasia,  Sensory. 
Sensory  centres,  699 
Septiciemia,  324 

definition  of,  324 
diagnosis  of,  325 
morbid  anatomy  of,  325 
prognosis  of,  32() 
symptomatology  of,  324 
treatment  of,  326 
Septicaemia  and  pvaunia,  diagnosis  of,  from 
malarial  fever,  328,  429 
from  scarlatina,  222 
from  typhoid  fever,  328 
Serratus  palsy,  843 
.Sewage,  test  f"or,  30 
Sewage-disposal,  33 
Sewer-air,  bacteria  in,  12 
!  Sewer-gas  in  etiology  of  diphtheria,  377 
I  Sewers,  35 
'  Sex  in  etiology  of  acromegaly,  863 

of  cerebral  li;emorriiage,  679 

(»f  enileosy,  612 

of  glanders,  513 

of  hysteria,  593 

of  local  syncope,  859 

of  locomotor  ataxia,  777 

of  mumps,  .■{().') 

of  panimyoclonus  multiplex,  8.'')7 

of  chronic  periencephulitia,  650 


902 


INDEX. 


Sex  in  etiology  of  scrofula,  337 

of  St.  Vitus's  dance,  628 
of  whooping  cough,  313 
Sexual  perversion,  579 
Shaven-beard      appearance      of      Peyer's 

patches,  61 
Sheep-pox,  287 

Ship  fever.     See  Typhus  Fever. 
Shock  in  typhoid  fever,  78 
Shoemakers,  mortality  of,  26 
Shopkeepers,  mortality  of,  26 
Sick  headache.     See  Migraine. 
Sighing,  early,  in  hydrophobia,  493 
Signal  symptom  in  brain  tumor,  720 
Silk-manufacturers,  mortality  of,  26 
Silver  nitrate  in  actinomycosis,  477 

in  bites  from  rabid  animals,  496 
in  influenza,  195 
in  relapsing  fever,  161 
in  typhoid  fever,  126 
Simon's  triangle,  268,  276 
Simple  continued  fever,  46,  48 
Singultus,  841 

Sinuses,  thrombosis  of,  primary,  694 
in  cachectic  conditions,  694 
in  children,  694 
in  chlorosis  and  anaemia,  694 
secondary,  in  erysipelas,  otitis  me- 
dia, and  pytemic  conditions,  694 
Sixth  nerve,  paralysis  of,  821 
Skin,  appearance  of,  in  scleroderma,  865 
in  scrofula,  340 
in  typhoid  fever,  70 
Skull,  changes  of,  in  acromegaly,  863 
in  chronic  hydrocephalus,  724 
in  hereditary  syphilis,  362 
Sleep,  659 

accidents  of,  663 
disorders  of,  659 
morbid,  661 
reflex,  662 
treatment  of,  664 
types  of,  662 
Sleep  palsies,  843 
Small-pox,  261 
abortive,  273 
cause  of,  12,  264 
complications  of,  277 
confluent,  273 

contagious  principle  of,  263 
contagiousness  of,  262 
corymbose  eruption  in,  275 
definition  of,  261 
diagnosis  of,  277 
discrete,  270 
eruption  in,  268 
etiology  of,  262 
haemorrhages  in,  274 
hsemorrhagic,  273 
initial  eruptions  in,  267 
invasion  in,  266 

mucous  membranes  in,  267,  272 
nervous  symptoms  in,  267 
pain  in,  267 

period  of  incubation  in,  265 
prognosis  of,  280 


Small-pox,  prophylaxis  of,  280 
second  attacks  of,  263 
secondary  fever  in,  272 
statistics  of  diminution  of,  by  vaccina- 
tion, 288 
susceptibility  to,  262 
symptomatology  of,  265 
synonyms  of,  261 
temperature  in,  272 
treatment  of,  281 
umbilication  of  eruption  in,  271 
vaccination  during,  281 
Small-pox,  diagnosis  of,  from  cerebro-spinal 
fever,  179,  278 
from  measles,  278 
from  meningitis,  278 
from  pneumonia,  278 
from  scarlatina,  279 
from  syphilis,  280 
from  typhoid  fever,  278 
from  typhus  fever,  278 
from  varicella,  301 
Snuffles,  365 

Sodium  bicarbonate  in  scarlatina,  228 
Softening  of  the  brain.   See  Periencephalitis, 

Clironic. 
Soil  in  etiology  of  cholera,  438 
of  diphtheria,  377 
of  malarial  fevers,  411 
micro-organisms  in,  29 
typhoid  bacillus  in,  57 
Solitary   glands,    changes   in,   in    typhoid 

fever,  61 
Somnambulism,  663 
Somnolence  in  brain  syphilis,  728 
in  hysteria,  598 
in  typhoid  fever,  78 
Sordes  in  typhoid  fever,  82 

in  typhus  fever,  141 
Sore  throat.     See  Angina. 
Spasms,  525 

in  antero-lateral  sclerosis,  791 

in  cerebro-spinal  fever,  173 

in  cholera,  442 

of  diaphragm,  841 

in  tetanus,  467 

of  facial  muscles,  forms  of,  832 

hypoglossal,  840 

of  laryngeal  muscles  in  hydrophobia, 

493 
of  muscles  of  mastication,  826 
of  ocular  muscles,  824 
in  paramyoclonus  multiplex,  857 
of  pharyngeal  muscles,  836 
Spastic  diplegia,  708 

Spastic  paraplegia.   See  Antero-lateral  Scle- 
rosis and  Paraplegia,  Infantile  Spastic. 
Special-sense  aurae  in  epilepsy,  615 
Special-sense  centres,  609 
Special    senses,  disorders   of,   in    typhoid 

fever,  80 
Speech,   changes   in   the,    in    Friedreich's 
ataxia,  798 
in  glosso-labial  paralysis,  803 
in  hypoglossal  paralysis,  839 
loss  of.     See  Aphasia. 


INDEX. 


903 


Speech  in  paralysis  agitans,  640 

scanning,  in  chronic  periencephalitis, 
553 

in  insular  sclerosis,  712 
Sphincters,    paralysis   of,    in    diphtheritic 
paralysis,  384 

in  hseuiatorrhachis,  741 
in  liysteria,  (503 

in  multiple  alcoholic  neuritis,  808 
in  acute  myelitis,  754 
in  chronic  myelitis,  760 
in  spinal  apoplexy,  746 
in  subacute  metallic  poliomyelitis, 
772 
Spinal  accessory  nerve,  paralysis  of,  837 
Spinal  apoplexy,  745 

etiology  of,  745 
symptoms  of,  7-46 
Spinal  atrophies,  diagnosis   of,  from   idio- 
pathic  muscular   atrophies,  855 
Spinal  concussion,  744 
Spinal  contractures,  diagnosis  of,  from  cere- 
bral contractures,  792 

from  hysterical   contractures, 
7i)2 
Spinal  cord,  abscess  of,  747 
antemia  of,  744 

anatomy  and  physiology  of,  737 
apoplexy  of,  745 
concussion  of,  744 
embolism  and  thrombosis  of  ves- 
sels of,  74fi 
hypenemia  of,  744 
localization  of  functions  of,  739 
acute  meningitis  of,  741 
chronic  meningitis  of,  743 
tumors  of,  747 

diagnosis  of,  748 
white  softening  of,  747 
sypiiilis  of,  734 
Spinal  irritation,  600 
Spinal  membranes,  hfemorrhage  into,  741 
Spinal  nerves,  lesions  of,  84U 
Spinal  neurasthenia,  643 
diagnosis  of,  644 
symptomatology  of,  643 
treatment  of,  'J44 
Spirillum  Obermeierii,  12,  151 
Spleen,  abscess  of,  in  relapsing  fever,  158 
in  typhoid  fever,  93 
enlargement    of,    in    acute    ascending 
paralysis,  749,  750 
in  antlirax,  480 
in  hereditary  syphilis,  364 
in  influenza,  187 
in  malarial  fevers,  412,  423,  432 
in  miliary  fever,  202 
in  mill<  sickness,  205 
in  mountain  fever,  207 
in  relapsing  fever,  155 
in  typhoid  fever,  68 
in  typhus  fever,  141 
infarction  of,  in  pyicinia,  327 
in  relapsing  fever,  \M 
in  typhoid  fever,  64 
rupture  of,  in  relai)sing  fever,  153 


Spleen,  rupture  of,  in  typhoid  fever,  64.  95 

tubercles  in,  in  acute  miliarv  tubercu- 
losis, 331 
Splenization  of  lungs  in  typhoid  fever,  i)i.\ 
Sponging  in  diphtheria,  395 

in  malarial  fever,  421 

in  sweats  of  pya^uia,  328 

in  typhoid  fever,  1 18 

in  yellow  fever,  461 
Sporadic  cases  of  typhoid  fever,  60 
Spurious  hydrocephalus.  678 

hydrophobia,  595 
Sputum,  influenza  bacilli  in.  185,  187 
S(juill  in  influenza,  195 
Stadium  paralyticum  in  hydrophobia.  494 
Sta])hylococci  in  diphtheria,  373 

in  metastatic  ])arolitis,  310 

in  pya?mia,  326 

in  small-)>ox,  264 
Stajdiylococcus  pyogenes  albus,  11 

aureus,  11 

citreus,  11 
Static  ataxia  in  Friedreich's  ataxia,  797 

nystagmus  in  Friedreich's  ataxia,  798 
Status  epilei)ticus.  614,  621 
Steam  in  dijjhtheria,  392 

effect  of,  upon  poison  of  scarlatina.  213 

superheated,  as  a  disinfectant,  17 
Steppage  gait  in  external    pojiliteal  nerve 
paralysis,  847 

in  multiple  neuritis,  811 
Stercoraceous  vomiting  in  hysteria.  603 
Sterilization,  15 

by  steam,  apparatus  for,  17 
Stertorous   breatliing    in  cerebral   hienior- 

rhage,  682 
Stimulants  in  anthrax,  483 

in  cerel)ro-spinal  fever,  182 

in  cholera,  449 

in  diphtheria,  395 

in  erysi])elas,  403 

in  milk  sickness,  206 

in  pyjeniia,  328 

in  sei>tica?mia,  326 

in  tyjihoid  fever.  130,  131 

in  tyjiiuis  fever,  148 

in  yellow  fever,  4(>1 
Stomach,  changes  in,  in  yellow  fever,  455 
Stomatitis  in  measles,  243 

in  typhoid  fever,  91 
Stomatitis,    diagnosis    of,    from   hereditary 

sypiiilis,  366 
Stools  of  cholera,  441 

of  typhoid  fever,  84 
Strabisiiius,  822 

in  eerebro-sjiinal  lever,  173 

in  hysteria,  599 

early,  in  locoinntor  ataxia,  785 

in  tniierculciis  meningitis,  672 
Strawberry  tongue  in  searlaliini,  217 
Streptococci  in  diphllieria,  373 

in  etiology  of  pseudo-diphtheria,  876 

in  measles,  236 

in  pya'mia.  326 

in  r<c:u°!atina,  213 

in  sni;ill-iM)x,  264 


904 


INDEX. 


Streptococcus  erysipelosus,  397 

inoculation  of,  in  tumors,  404 
pyogenes,  11 
Strophanthus  in  typhoid  fever,  131 
Strychnine  in  angio-neurotic  oedema,  862 
in  confusional  insanity,  574 
in  delirium  tremens,  561 
in  di{)htheria,  395 
in  influenza,  195 
in  acute  poliomyelitis,  769 
in  subacute  metallic  poliomyelitis,  772 
in  subacute  poliomyelitis,  771 
in  relapsing  fever,  161 
in  typhoid  fever,  130,  132 
in  typhus  fever,  149 
Strychnine-poisoning,   diagnosis    of,    from 

tetanus,  468 
Stupor,  definition  of,  659 
St.  Vitus's  dance,  627 
course  of,  631 
diagnosis  of,  631 
etiology  of,  628 
heart  murmurs  in,  631 
pathology  of,  628 
symptomatology  of,  629 
synonyms  of,  627 
treatment  of,  632 
Subacute  diffuse  anterior  spinal  paralysis 

of  Duchenne,  nature  of,  810 
Subluxation  in  locomotor  ataxia,  782 
Subsultus  tendinum  in  typhoid  fever,  81 

in  typhus  fever,  140 
Sudamina  in  cerebro-spinal  fever,  174 
in  ephemeral  fever,  48 
in  relapsing  fever,  155 
in  acute  miliary  tuberculosis,  332 
in  typhoid  fever,  71 

prognostic  significance  of,  112 
in  typhus  fever,  143 
Sudden  death  in  cholera,  443 
Sudoral  form  of  typhoid  fever,  70,  102 
Sugar  in  urine.     See  G'li/co.furia. 
Sulphanilic  acid  test,  89 
Sulphate  of  copper  as  a  germicide,  20 
of  iron  as  a  deodorant,  20 

in  purification  of  water,  35 
Sulphites  in  typhoid  fever,  127 
Sulphonal  in  epilepsy,  624 
in  influenza,  195 
in  simple  insomnia,  661 
in  typhoid  fever,  127 
Sulphur  as  a  disinfectant,  19 
Sulphuric  acid  as  a  disinfectant,  20 

in  typhoid  fever,  131 
Sulphurous  acid  as  a  disinfectant,  19 

in  typhoid  fever,  126 
Sunstroke.     See  Thermic  Fever. 
Superficial  reflexes,  524 
Surgical  scarlatina,  211 
Susceptibility  to  fever,  46 
Suspension,  application  of,  643 
in  locomotor  ataxia,  789 
in  s])inal  syphilis,  735 
in  syringomyelia,  775 
in  traumatic  neurasthenia,  643 
Sweating  in  cholera,  442 


Sweating  in  influenza,  188 
in  intermittent  fever,  414 
in  miliary  fever,  202 
in  2>yfemia,  327 
in  relapsing  fever,  156 
in  trichinosis,  507 
in  acute  miliary  tuberculosis,  332 
in  typhoid  fever,  70,  102 
in  typho-malarial  fever,  432 
in  typhus  fever,  143 
Swine  erysipelas,  cause  of,  12 
Symmetrical  gangrene,  860 
Syncope  in  diphtheria,  384 

local,  859 
Syphilides  in  acquired  syphilis,  secondary, 
352 
tertiary,  351 
in  hereditary  syphilis,  363,  365 
Syphilis,  acquired,  345 

bacillus  of,  346 

cachexia  in,  353 

cause  of,  12,  346 

contagiousness  of,  345 

course  of,  354 

definition  of,  345 

diagnosis  of,  354 

distribution  of,  346 

etiology  of,  345 

extra-genital  sources  of,  345 

gumnuita  in,  350 

inoculability  of,  347 

latent  period  of,  347 

lymphatic  glands  in,  .349 

morbid  anatomy  of,  348 

periods  of,  347 

primary  period,  lesions  of,  348 

prognosis  of,  355 

prophylaxis  of,  356 

relation  of,  to  other  diseases,  356 

secondary  period,  lesions  of,  349 

sequelte  of,  355 

symptomatology  of,  352 

synonyms  of,  345 

terminations  of,  354 

tertiary  period,  lesions  of,  350 

treatment  of,  356 

visceral  lesions  in,  351 
Syphilis,     acquired,     diagnosis     of,     from 
measles,  355 

from  rubella,  259 

from  small-pox,  280 
Syphilis  of  the  brain,  726 

diagnosis  of,  729 

pathology  of,  726 

prognosis  of,  731 

symptomatology  of,  726 

treatment  of,  731 

types  of,  727 
Syphilis  of  the  cord,  734 

diagnosis  of,  734 

pathology  of,  734 

prognosis  of,  735 

sym])tomatology  of,  734 

treatment  of,  735 
Syphilis  in  etiology  of  locomotor  ataxia,  777 

of  chronic  periencephalitis,  651 


INDEX. 


905 


Syphilis,  hereditary,  360 
conceptional,  360 
diagnosis  of,  366 
etiology  of,  361 

general  morbid  processes  in,  362 
morbid  anatomy  of,  363 
placenta  in,  362 
prognosis  of,  366 
sequelfe  of,  366 
symptomatology  of,  365 
synonyms  of,  361 
three  periods  of,  365 
treatment  of,  367 
Syphilis,    hereditary,   diagnosis    of,    from 
stomatitis,  366 
from  rachitis,  366 
from  scrofula,  342 
Syphilis  of  nerves,  735 
Syphilitic  callus,  734 
coma,  726 

encephalopathies,  353 
fever,  352 
Syphilitics,  question  of  marriage  of,  8,  367 
Syphilization,  condition  of,  362 
Syphiloma  of  brain,  717 
Syringomyelia,  772 
diagnosis  of,  775 
pathology  of,  772 
symptomatology  of,  773 
treatment  of,  775 
Syringomyelia,  diagnosis  of,  from  cervical 
pachymeningitis,  775 
from  Morvan's  disease,  775 
from  multiple  alcoholic   neuritis, 
775 

TABES,  forms  of,  811 
Tabes  dorsalis.    See  Locomotor  Ataxia. 
Tabes  ergotica,  778 

Tache  cerebrale  in  cerebro-spinal  fever,  174 
in  tuberculous  meningitis,  672 
in  typhoid  fever,  72 
Taches  bleuatres  in  typhoid  fever,  72 
Tailors,  mortality  of,  26 
Tannic  acid  in  cpistaxis.  131 
in  typhoid  fever,  129 
Tartar  emetic  in  typhus  fever,  149 
Taste,  disturbances  of  the  sense  of,  835 

tests  for  the  sense  of,  835 
Teeth,  anomalies  of,  in  hereditary  syphilis, 
364 
loss  of,  in  facial  hemiatrophy,  867 
Telegrapher's  cramj).     See  Occupation  Neu- 
roses. 
Temperature  in  acute  ascending  |)aralysi.s, 
74!) 
in  bilious  intermittent  fever,  426 
in  cerebral  li;einorrhage,  682 
in  cerebro-spinal  fever,  175 
in  cholera,  443 
in  delirium  tremens,  559 
in  dengue,  198 
in  (lij)htheria,  381 
in  ejMlepsy,  614 
in  erysioelas,  399 
in  glanders,  514 


Temperature  in  hysteria,  602       ' 

in  influenza,  187 

in  intermittent  fever,  414 

in  measles,  238 

in  miliary  fever,  202 

in  mountain  fever,  207 

in  multiple  neuritis.  807 

in  mumps,  307 

in  acute  myelitis,  754 

in  acute  periencephalitis,  549 

in  chronic  periencephalitis,  555 

in  acute  poliomyelitis,  763 

in  pya-mia,  327 

in  relapsing  fever,  155 

in  remittent  malarial  fever,  424 

in  rubella,  258 

in  scarlatina,  215 

in  secondary  syphilis,  352 

in  septicaemia,  324 

in  small-pox,  272 

in  St.  Vitus's  dance,  630 

in  tetanus,  467 

in  thermic  fever,  646 

in  trichinosis,  507 

in  acute  miliary  tuberculosis.  332,  333 

in  tuberculous  meningitis,  672 

in  tyj)hoid  fever,  72 

in  ty])ho-malarial  fever.  432 

in  typhus  fever,  140 

in  whooping  cough,  315 

in  yellow  fever,  455,  456 
Temperature,  inverted,  in  typhoid  fever,  76 
Temperature,  oscillating,  in  i)yiemia,  327 
Temperature,  subnornuil,  in  cerebral  htem- 
orrhage,  682 
in  cliolera,  442 

in  confusional  insanity.  571,  572 
in  heat-i'xhaustion,  645 
in  hysteria,  598 
in  intermittent  fever,  416 
in  malarial  cachexia,  432 
in  syneo|ial  cardiac  epilepsy,  618 
in  tuberculous  meningitis,  672 
Temporal  lobe,  auditory  centre  in,  699 

tumors  of,  721 
Tender  points  in  trifacial  neuralgia,  826 
Tendon  reflexes.     See  Hrjicrex. 
Terminal  dementia,  575 
Tertian  ague,  405 
Test  for  typhoid  fever  in  urine,  89 
Tetai)ine,"465 
Tetanus,  462 

antitoxines  in,  470 

bacillus  of,  463 

cause  of,  1 1.  4()3 

definition  of,  462 

diagnosis  of,  467 

etiology  of,  463 

iniinuMity  Ironi,  470 

morbid  anatomy  of.  466 

mortality  of,  Hi'.' 

period  of  incubation  in,  466 

prognosis  of,  46S 

propliyia.xis  of,  469 

surgical  measures  in,  470 

.synipfoMiatology  of,  466 


906 


INDEX. 


Tetanus,  treatment  of,  469 
Tetanus,  diagnosis  of,  from  hydrophobia, 
468,  494 
from  hysteria,  468 
from  meningitis,  468 
from  strychnine-poisoning,  468 
from  tetany,  468,  639 
Tetany,  688 

etiology  of,  638 
symptomatology  of,  638 
following  thyroidectomy,  638 
treatment  of,  639 
Tetany,  diagnosis  of,  from  tetanus,  468,  639 
Thalamus  opticus,  tumors  of,  721 
Thallin  in  rehipsing  fever,  161 
Therapeutic  test  in  syphilis,  355 
Thermic  anaesthesia  in  hysteria,  600 

in  syringomyelia,  773 
Thermic  fever,  645 

continued,  616 
etiology  of,  645 
pathology  of,  647 
sequelse  of,  649 
symptomatology  of,  646 
treatment  of,  648 
Thermic  sense,  testing  of,  528 
Third  nerve,  paralysis  of,  819 

recurrent  paralysis  of,  820 
Thirst  in  cerebro-spinal  fever,  176 
in  cholera,  441 
in  hydrophobia,  493 
in  relapsing  fever,  155 
in  typhoid  fever,  82 
in  typhus  fever,  141 
Thomsen's  disease,  856 

definition  of,  856 
etiology  of,  856 
symptomatology  of,  856 
Thoracic  form  of  typhoid  fever,  102 
Thoracic  duct,  spread  of  tuberculosis  from, 

329 
Thrombosis  in  scleroderma,  865 
in  typhoid  fever,  93 
of  femoral  vein  in  typhoid  fever,  133 
Thrombosis  of  cerebral  arteries.     See  Ern- 
bolism   and    Thrombosis   of   Cerebral 
Arteries. 
Thrombosis   of  cerebral   sinuses,  primary, 
694 
secondary,  694 
symptoms  of,  694 
treatment  of,  695 
Thymol  in  scarlatina,  229 
in  trichinosis,  511 
in  typhoid  fever,  127 
Thymus  gland  in  acromegaly,  863 

in  hereditary  syphilis,  364 
Thyroid  gland  in  acromegaly,  863 
Tic  convulsif.     See  Aufomaiic  Chorea. 
Tic  douloureux,  826 
Tinnitus  aurium,  833 

in  cerebro-spinal  fever,  174 
Titubation,  722 
Tongue  in  acromegaly,  863 

in  cerebro-spinal  fever,  176 
in  dengue,  198 


Tongue  in  erysipelas,  399 

in  milk  sickness,  205 

in  relapsing  fever,  155 

in  scarlatina,  217 

in  small-pox,  272 

in  syphilis,  352 

in  typhoid  fever,  68,  82 

in  typhus  fever,  138 
Tongue,  atrophy  of,  803,  .839 
Tongue,  spasm  of,  840 
Tongue,  tremor  of,  in  glosso-labial  paralysis, 
803 
in  insular  sclerosis,  712 
in  chronic  periencephalitis,  553 

ulcer  of,  in  typhoid  fever,  91 
in  whooping  cough,  317 
Tonsillitis,  diagnosis  of.  from  diphtheria, 

386 
Torticollis,  congenital,  838 

facial  asymmetry  in,  838 

spasmodic,  838 

treatment  of,  839 
Toxa3mic  epilepsies.     See  Epilepsy. 
Toxaemic  insanities,  559 
Toxalbumin  in  typhoid  fever,  58 
Toxines  in  diphtheria,  374 
Tracheotomy  in  diphtheria,  393 

in  typhoid  fever,  66,  95 
Trance  in  hysteria,  598 
Transfusion  of  blood  in  typhoid  fever,  131 
Traumatic  neurasthenia,  642 

treatment  of,  642 
Tremors  in  delirium  tremens,  559 

in  Friedreich's  ataxia,  797 

in  insular  sclerosis,  712 

in  paralysis  agitans,  639 

in  i)aramyoclonus  multiplex,  857 

in  chronic  periencephalitis,  553 

in  typhoid  fever,  81 

in  writer's  cramp,  652 
Tremors,  causes  of,  526 

definition  of,  525.     See,  also,  Intention 
Tremors. 
Trephining  in  brain  abscess,  716 

in  brain  tumor,  723 

in  epilepsy,  622,  626 

in  meningitis,  676 
Trichina  spiralis,  9,  22,  499 
anatomy  of,  501 
distribution  of,  507 
Trichinosis,  499 

definition  of,  499 

diagnosis  of,  508 

duration  of,  508 

historical  note  on,  499 

morbid  anatomy  of,  507 

mortality  of,  510 

prognosis  of,  510 

prophylaxis  of,  510 

symptomatology  of,  505 

treatment  of,  510 
Trichinosis,  diagnosis  of,  from  cholera,  509 
from  polymyositis,  509 
from  rheumatic  fever,  509 
from  typhoid  fever,  108,  509 
Trigeminus  nerve.     See  Fifth  Nerve. 


INDEX. 


907 


Trismus,  826 

in  eerebro-spinal  fever,  173 
in  tetanus,  46t) 
in  trichinosis,  ,")()() 
in  typhoid  fever,  82 
Trophic   changes   in    amyotrophic    lateral 
sclerosis,  7i)4 
in  antpsthctic  leprosy,  371 
following    cerebral     haemorrhage, 

683 
in  fifth-nerve  paralysis,  825 
in  localized  neuritis,  806 
in  locomotor  ataxia,  782 
in  Morvan's  disease,  775 
in  multiple  neuritis,  807 
in  multiple  alcoholic  neuritis,  808 
in  acute  myelitis,  755 
in  acute  poliomyelitis,  764 
in  progressive  muscular  atrophy, 

801 
in  spinal  apoplexy,  746 
in  syringomyelia,  774 
Trophic  and  vaso-motor  disorders,  859 
Trousseau's   phenomenon    in   tetany,   468, 

639 
Tubercle  of  brain,  717 
Tubercle  bacilli  in  milk,  22 
in  soil,  29 

in  sputum  in  acute  miliary  tuber- 
culosis, 333 
in  tubercles  in  acute  miliary  tu- 
berculosis, 331 
Tubercle*,  distribution  of,  in  lei)rosy,  370 
in  acute  miliary  tuberculosis,  331 
in  the  choroid  in  acute  miliary  tuber- 
culosis, 332 
in  tuberculous  meningitis,  673 
Tubercula  dolorosa,  812 
Tuberculin,  action  of,  in  tuberculosis,  330 
Tuberculosis  following  measles,  244,  249 

following  typiioid  fever,  97 
Tuberculosis,  acute  miliary,  329 
course  of,  333 
definition  of,  329 
diagnosis  of,  334 
duration  of,  334 
eruptions  in,  332 
etiology  of,  329 
invasion  in,  332 
morbid  anatomy  of,  331 
physical  signs  in,  333 
j)rogn()sis  <jf,  334 
symptomatology  of,  332 
treatment  of,  334 
ty[)hoi(l  and  intermittent  types 
of,  333 
Tuberculosis,    acute  miliary,  diagnosis  of, 
from  broncliitis,  334 
from  malarial  fever,  334 
from  typhoid   fever,  107, 
334  ' 
Tuljereulosis,  peritoneal,  diagnosis  of,  from 

typhoid  fever,  108 
Tuberculous  iiieniiigitis,  670 

morbid  anatomy  of,  671 
symptomatology  of,  *i7) 


Tuberculous  meningitis,  diagnosis  of,  from 

eerebro-spinal  fever,  177 
Tumors,  inoculation  of  streptococcus  ery- 

sipelosus  in.  404 
Tumors  of  the  brain.     See  Brain,  Tumors 

of. 
Turpentine  in  eerebro-spinal  fever,  183 

in  typhoid  fever,  126,  130,  131 
Tvmpanites  in  relapsing  fever,  155 

in  tvphoid  fever,  83,  130 
Typhoid  bacillus,  11,  55 
in  ice,  32 
in  sewage,  33 
in  soil,  29 
in  water,  30 
Typhoid  fever,  52 

abortive  cases  of,  78 

bacillus  of,  11,  55 

causes  of  death  from,  110 

in  children,  75,  103 

complications  and  sequelae  of,  89 

definition  of,  52 

diagnosis  of,  105 

duration  of.  109 

eruption  in,  70 

etiology  of,  53 

ground-water  in  etiology  of,  28 

history  of,  52 

milk  in  etiology  of,  23 

morbid  anatomy  (»f,  60 

mortality  of,  110 

prognosis  of,  1 11 

prophylaxis  of,  113 

ptomaines  in,  58 

recrudescences  in,  78,  104 

relapses  in,  103 

seconil  attacks  of,  105 

septiciemic  or  malignant  form  of, 

102 
symptomatology  of,  67 
synonyms  of.  52 
treatment  of,  1 13 
varieties  of,  98 
Typhoid  fever,  diagnosis  of,  from  cerebro- 
spinal fever,  106,  178 
from  eliolcra,  445 
from  ephemeral  fever,  49,  107 
from    gastro-eiiteric    catarrh, 

108 
from  iii(lu(  iiza.  1<»S,  193 
from  malarial  fever,  107,  429 
from  relapsing  fever,  107,  159 
from  scarlatina,  108 
from  trichinosis,  108,  509 
from  acute  miliarv  tuberculo- 
sis, 1(17,  334 
from  typhus  fever,  107,  147 
irom  ura'Miia,  109 
Tvphoid  |)neuinonia,  9S 
Typhoid  state,  69 

in  cholera,  444 
in  diplitiieria,  3H3 
in  erysipelas,  400 
in  septica'uiia,  ;)25 
in   thrombosis  of  cerebral  sinuacH, 
695 


908 


INDEX. 


Tj'phoid  state  in  acute  miliary  tuberculosis, 
332 
in  tuberculous  meningitis,  672 
in  typhoid  fever,  69 
in  yellow  fever,  457 
Typho-malarial  fever.   See  Malarial  Fevers. 
Typhotoxicon,  58 
Typhus  fever,  134 

complications  and  sequelae  of,  144 
definition  of,  134 
diagnosis  of,  146 
duration  of,  145 
etiology  of,  1 34 
history  of,  134 
morbid  anatomy  of,  137 
mortality  of,  145 
prognosis  of,  145 
symptomatology  of,  138 
synonyms  of,  134 
treatment  of,  147 
Typhus  fever,  diagnosis  of,  from  bubonic 
plague,  147 

from  cerebro-spinal  fever,  146, 

178 
from  measles,  147,  250 
from  relapsing  fever,  159 
from  small-pox,  278 
from  typhoid  fever,  107,  147 
Typhus  siderans,  144 
Tyroma,  717 

ULCER,  endemic  tropical,  cause  of,  12 
lingual,  in  whooping  cough,  316 

perforating,  in  anaesthetic  leprosy,  371 
in  locomotor  ataxia,  783 
Ulceration  in  syphilis,  350 

of  cheek  in  typhoid  fever,  91 

of  intestine  in  typhoid  fever,  62 
Ulcers  in  glanders,  514 

scrofulous,  340 

of  oesophagus  in  typhoid  fever,  65 
Ulnar  nerve,  affections  of,  844 
Umbilication  in  small-pox,  271 

in  lesion  of  vaccination,  296 

in  varicella,  300 
Unconsciousness.     See  Coma. 
Uraemia,  diagnosis  of,  from  typhoid  fever, 

109 
Urea,  excretion  of,  in  cholera,  441 

in  the  malarial  paroxysm,  417 
in  typhoid  fever,  89 
Urine  in  bilious  intermittent  fever,  426 

in  cerebro-si)inal  fever,  169,  176 

in  cholera,  441 

in  diphtheria,  383 

in  hsematuric  intermittent  fever,  427 

in  hysteria,  602 

in  malarial  fever,  416 

in  melancholia,  565 

in  acute  myelitis,  754 

in  relapsing  fever,  158 

in  typhoid  fever,  88 

in  typhus  fever,  143 

in  yellow  fever,  456 
Urine,  retention  of,  in  hysteria,  609 
in  locomotor  ataxia,  788 


Urine,  retention  of,  in  acute  myelitis,  758 
in  chronic  myelitis,  760 
in  typhoid  fever,  89 
test  of,  for  typhoid  fever  (diazo-reac- 

tion),  89 
typhoid  bacillus  in,  56 
Urticaria,  giant.    See  Angio-neuroticCEdema. 

VACCINATION,  283 
age  at  which  to  perform,  295 
definition  of,  283 

degree  of  immunity  conferred  by,  288 
duration   of  immunity   conferred  by, 

291 
lesion  of,  296 
points  for,  295 
results  of,  15,  288 
during  small-pox,  281 
susceptibility  to,  295 
symptoms  following,  296 
Vaccination  as  protective   against  scarla- 
tina, 227 
Vaccinia.     See  Vaccination. 
Valerian  in  typhus  fever,  149 
Valerianate  of  ammonium  in  tvphoid  fever, 

128 
Varicella,  297 

complications  of,  302 
definition  of,  297 
diagnosis  of,  301 
eruption  in,  299 
etiology  of,  297 
historical  note  on,  297 
period  of  incubation  in,  299 
prophylaxis  of,  302 
symptomatology  of,  299 
synonyms  of,  297 
treatment  of,  302 
Varicella,  diagnosis    of,    from    small-pox, 

301 
Variola.     See  Small-pox. 
Variola  nigra,  274 
Variola  sine  eruptione,  268 
Varioloid,  275 

Vaseline  for  inunction  in  scarlatina,  226 
Vaso-motor  disturbances  in  hysteria,  601 
in  migraine,  657 
in  multiple  neuritis,  807 
in  acute  myelitis,  755 
in  chronic  periencephalitis,  555 
in  syringomyelia,  773 
spasm  in  the  malarial  paroxysm,  414 
theory  in  epilepsy,  622 
Vaso-motor  and  trophic  disorders,  859 
Veins,  pulmonary,  spread  of  tuberculosis 

from,  330 
Venesection  in  cerebral  haemorrhage,  692 
in  acute  myelitis,  756 
in  spinal  hyperaemia,  745 
in  acute  spinal  meningitis,  742 
Ventilation,  37 

diseases  due  to  imperfect,  37 
Ventricles  of  brain,  dilatation  of,  in  brain 
tumor,  718 
ill  hydrocephalus,  723 
Ventricular  lucinorrhage,  681 


IX  I)  EX. 


909 


Veratrum  viride  in  cerebro-spinal  fever,  1S8 
Vermiform  appendix,  ulcer  of,  in  typhoid 

fever,  ()2 
Vertebral  artery,  occlusion  of,  691 
Vertiginous  status,  (510 
Vertigo  in  brain  tumor,  719 

in  cerebellar  disease,  722 
Vertigo,  (309 

aural,  Gil 

cardiac,  (JIO 

essential,  (U2 

gastric,  (ilO 

organic,  GIG 

peripheral,  (310 

special  sense,  611 

toxu'mic,  611 

treatment  of,  612 
Vibrio  of  Mcntscluiikoff,  12 
Visual  aurse  in  epilepsy,  615 
Voice.     See  Speech. 
Volitional  tremor,  712 
Voltolini's  disease,  (311 
Vomit,  black,  in  yellow  fever,  456 

cofiee-ground,  in  locomotor  ataxia,  779 
Vomiting  in  angio-neurotic  eedema,  862 

in  anthrax,  481 

in  bilious  intermittent  fever,  426 

in  cerebellar  disease,  722 

in  cerebral  abscess,  715 

in  cerebral  tumor,  719 

in  cerebro-spinal  fever,  175 

in  cholera,  441 

in  dengue,  198 

in  ha?maturic  intermittent  fever,  427 

in  hysteria,  602 

in  influenza,  190 

in  locomotor  ataxia,  779 

in  measles,  247 

in  meningitis,  674 

in  migraine,  (357 

in  milk  sickness,  205 

in  acute  j)oliomyelitis,  763 

in  Raynaud's  disease,  861 

in  relapsing  fever,  155 

in  remittent  malarial  fever,  424 

in  scarlatina,  215 

in  scarlatinal  nephritis,  219 

in  small-j^ox,  266 

in  tlicniiic  fever,  646 

in  trichinosis,  50.") 

in  tuberculous  meiiiuiritis,  672 

in  tyjjhoid  fever,  88,  128 

in  typhus  fever,  138 

in  whooping  cougii,  315 

in  yellow  fever,  455,  456 

"ll^ALKINCJ  typhoid  fever,  101 
Vf    W'allcriaii  (Icgcncration,  (I'.tS 
Warl)urg's  tincture  in  intermittent  malarial 

fever,  422 
Water  in  typlmitl  fever,  116 

in  ty]»lius  fever.  i4>> 
Water,  bacteriological  examination  of,  30 
contamination  of,  30 

by  alga-,  •". I 
filtration  of.  .''.1 


Water,  micro-organisms  in,  29 
purification  of,  31 
supply  of,  29 
tests  of  puritv  of,  30 
typhoid  bacilli  in,  30,31,  57 
Water-bed  in  multijile  neuritis,  811 
in  acute  myelitis,  758 
in  tyi)hoid"fever,  130,  ]82 
Wernicke's  te.st  in  hemianopia,  819 
Westphal's  symptom,  780 
White  softening  of  the  brain,  (389 

of  the  spinal  cord,  747 
Whitlows  in  Morvan's  disease,  775 
Whooping  cough,  311 

age  and  sex  in  etiology  of,  313 

comf)licati(»ns  of,  317 

contagiousness  of,  314 

diagnosis  of,  318 

emphysema  in,  317 

etiology  of,  312 

historical  note  on,  311 

lingual  ulcer  in,  317 

paroxysm  in,  315 

prognosis  of,  3 lit 

prophylaxis  of,  320 

symptomatology  of,  314 

synonvms  of,  3il 

treatnient  of,  320 

vomiting  in,  315 
Will,  conditions  altering  the,  530 

qualities  of  the,  529 
"Woods"  in  syphilis,  733 
Wool-manufacturers,  mortality  of,  26 
Word-blindness,  703 
Word-deafness,  704 
Wormian  bones  in  hydrocephalus,  724 
Wrist-drop  in  musculo-spinal  i)aralysi.s,  844 

in  .symmetrical  gangrene,  861 
Writers'  cramp.     See  Ocntpnfion  Neuroses. 
Wry-neck.     See  Torticollis. 

YELLOW  fever,  451 
contagiousness  (d',  452 
definition  of,  4.")1 
distril)uii(»n  of,  451 
etiology  of,  451 
exceptional  cases  of,  456 
imnuiiiity  from,  453 
morbid  anatomy  of,  454 
mortality  of,  458 
prognosis  of,  458 
prophylaxis  of,  459 
quarantine  against,  459 
race  in  etiology  of,  453 
sym|)tomatology  of,  455 
synonyms  of,  451 
treatment  of,  459 
Yellow  fever,  diagnosis  of,  from  acute  yel- 
low atrophy,  458 
from  dengue,  199 
from  m.ilarial  fevers,  429,  458 
from  relapsing  fever,  15'.l,  458 
Yellow  softening  of  the  brain,  6S9 

ZI.M.M  lOKLI.N'  type  of  progressive  myopa- 
thie  atntphy,  852 


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